1

THE MINISTRY OF HEALTH OF UKRAINE

ZAPORIZHZHIA STATE MEDICAL UNIVERSITY
Department of nervous diseases

NEUROLOGY IN TABLE
(Special neurology)

for practical employments for the students of the

4th course of II international faculty
speciality “General medicine” English medium of instruction

Second edition revised

Zaporizhzhia
2018
 2

UDC 616.8(075.8)
K80

Ratified on meeting of the Central methodical committee

of Zaporizhzhia State Medical University
(protocol № 2 from 22.11.2018)
and it is recommended for the use in educational process for foreign students.

Authors:
O. A. Kozyolkin – professor of Neurology, the Head of Department of
Neurology;
I. V. Vizir – docent of Neurology, Department of Neurology;
M. V. Sikorskay - docent of Neurology, Department of Neurology.

Reviewers:
V. V. Sivolap - Head of the Department of propaedeutics Internal Medicine,
Professor;

O. V. Kraydashenko – Head of the Department of clinical pharmacology,

pharmacy, pharmacotherapy and cosmetology, Professor.

Kozyolkin O. A.
Neurology in table (Special neurology): for practical employments
and for classroom work for the students of the 4th course of II
international faculty speciality “General medicine” English medium of
instruction / O. A. Kozyolkin, I. V. Vizir, M. V. Sikorskay. - 2nd ed.
revised. - Zaporizhzhia: [ZSMU], 2018. - 115 p.
 3

CONTENTS
CEREBRAL VASCULAR DISEASES. SLOWLY PROGRESSING AND 4
TRANSIENT DISTURBANCES OF CEREBRAL BLOOD CIRCULATION.
BRAIN STROKE
EPILEPSY AND NON-EPILEPTIC PAROXYSMAL STATES 12
INFECTIOUS DISEASES OF THE CENTRAL NERVOUS SYSTEM 15
AMYOTROPHIC LATERAL SCLEROSIS (ALS) 32
VERTEBROGENIC DISORDERS OF THE 34
PERIFERAL NERVOUS SYSTEM
DEMYELINATING DISEASE: MULTIPLE SCLEROSIS (MS), 40
ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM)
PERIPHERAL NERVOUS SYSTEM DISEASE (PNS). CLASSIFICATION. 47
POLYNEUROPATHY (GULLIAN-BARRE SYNDROME)
PERIPHERAL NERVOUS SYSTEM DISEASE (PNS). PlEXOPATHIES, 52
NEUROPATHY OF UPPER AND LOWER LIMBS. CRANIAL
NEUROPATHY
HEADACHE. CLASSIFICATION HEADACHE. MIGRAINE. 60
NEUROLOGICAL ASPECTS OF ACQUIRED IMMUNE DEFICIENCY 68
SYNDROME (AIDS)
NEUROSYPHILIS 73
HEREDITARY DISEASE OF NERVOUS SYSTEM 77
SOMATONEUROLOGIC SYNDROME 84
CEREBRAL PALSY (INFANT CEREBRAL PALSY) 89
SHEMA OF STUDY OF PATIENS WITH A NEUROLOGIST 90

INDEX OF DRUGS TO COMMON NEUROLOGICAL DISEASE 91

TESTS 94

A QUESTION IS FOR THE VERBAL QUESTIONING 109

REFERENCES 113
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THEMA: CEREBRAL VASCULAR DISEASES. SLOWLY PROGRESSING

AND TRANSIENT DISTURBANCES OF CEREBRAL BLOOD
CIRCULATION. BRAIN STROKE

Cerebrovascular disease (CVD), including stroke, is the third leading cause of

death in Ukraine and the leading cause of disability among senior people.
Cerebrovascular disease occurs when the blood vessels supplying the brain with
oxygenated blood are damaged or their function is compromised. If the blood flow
is severely restricted, depriving the brain of adequate oxygen even briefly, a stroke
can occur. It has been estimated that every 45 seconds, one person suffers from a
stroke, often with debilitating consequences or even death. One of four men and
one of five women over the age of 45 would suffer a stroke.

Anatomy of the cerebral vascular system

Four arteries supply the brain almost exclusively: two internal carotids and two
vertebral arteries. The contributions of blood flow to the brain of these systems in
the adult human brain are approximately three fourths of the total for the carotids,
and one fourth for the vertebrals. These vessels originate from branches stemming
out of the aortic arch. Internal carotid and vertebrobasilar arterial systems connect
at the base of the brain by arterial anastomosis and form Circle of Willis. The
arrangement of the brain's arteries into the Circle of Willis creates redundancies or
collaterals in the cerebral circulation. If one part of the circle becomes blocked or
stenosed or one of the arteries supplying the circle is blocked or narrowed, the
blood flow from other blood vessels can often preserve cerebral perfusion well
enough to avoid symptoms of ischemia.

Etiology of сerebrovascular disease

Atherosclerosis, arterial hypertension (> 140 mm Hg systolic, > 90 mm Hg
diastolic), a combination of atherosclerosis and arterial hypertension, vasculitis,
diabetes mellitus, blood diseases, elevated plasma fibrinogen, degenera tive
changes in the upper cervical spinal cord, heart and vascular pathology (atrial
fibrillation, valvular heart disease, mitral valve prolapse, myocardial infarction,
carotid stenosis), obesity.

Risk Factors for сerebrovascular disease

The risk of stroke increases with age and is higher in men than in women at any
age. Risk factors of CVD include: hyperlipoproteinemia (total cholesterol > 5.0
mmol/l, Low-density lipoprotein (LDL) > 3 mmol/l, High-density lipoprotein
 5

(HDL) < 0.9-1.2 minol/l), cigarette smoking, alcohol abuse (> 60 g of alcohol per
day in men, > 40 g in women), drug abuse (amphetamines, heroin, cocaine),
sedentary lifestyle.

Classification of cerebrovascular disease

Cerebrovascular disease

Initial manifestations of brain blood

supply insufficiency

Acute disturbances cerebral blood

circulation

Slowly progressing disturbances of

cerebral blood circulation

Acute disturbances cerebral

Transient ischemic attacks

Brain stroke

Ischemic stroke Hemorrhagic stroke

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Transient ischemic attacks (TIA)

A transient ischemic attack is defined as acute focal neurological deficit lasting
less than 24 hours. Attacks are usually much shorter, most episodes clearing
within 1 hour, only 5 % last longer than 12 hours. Miller Fisher first described the
phenomenology of TIAs as "prodromal fleeting attacks of paralysis, numbness,
tingling, speechlessness, unilateral blindness or dizziness," which preceded ce-
rebral infarction in patients with the occlusion of the internal carotid artery (ICA).

Signs and symptoms

General signs Focal signs

Headache, dizziness System of internal Lesion of sensory:

(vertigo), vomiting, carotid artery: lesion face, defeat of
noice, emocional of sensory: paresis of hearnin bulbar
disteturbances, general arm or leg, fingers, syndrome,
weakness, vasomotor transient lesion of vestibular disorders,
lesion (hyperhidrosis, speech convulsive lesion of memory
tachycardia, changes of serius
consciousnees

Diagnostic test TIA. Treatment principles

Examination of neurology status: Treatment principles include:

present focal signs, regressed focal
signs after 10’-24 hours, investigation: 1. Stabilization of blood pressure.
glucose, prothrombin time level. 2. Improvement of cardiac activity.
Lypidogram , carotid duplex,
ultrasonography, CT, MRI 3. Improvement of cerebral
activity.
4. Normalization of the
metabolism of the brain.
5. Combating swelling of the brain
improving venous outflow.
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Transient ischemic attacks

Treatment Prevention Differential

diagnosis

Diuretics, inhibitor 1. Correction of risk Vegetative-vascular

ACF, antagonists of factors (hypertension, crises
calcium blockers, atherosclerosis, Epileptic and
anticoagulant, diabetes mellitus, palpitations state
antiagregants, statins vasculitis, cardiac Stroke
rhythm) Hypoglycemia
Migraine
Alcochol and drug
intoxication
Positional vertigo

Ischemic stroke

Hypertension, atherosclerosis, diabetes

Etiology mellitus, vasculitis, disease of blood,
pathology of cordiac vascular anomalies
and over

Thrombosis
Pathogenesis Embolism
Vascular spasm

Atherotrombotic subtype
Cardioembolic subtype
Hemodynamic subtype
Lacunar subtype
Classification
Stroke-type hemorheological microoclusive

A completed stroke, which can cause

neurological deficits, that are either:
Clinical form - a minor stroke, when deficits
disappear during 21 days
- a major stroke (disabling stroke)
A stroke in evolution - a progressive
course of stroke development.
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Subtype of ischemic stroke

Ischemic stroke

Etiology: to defeat of the cerebral vessels due to

atherosclerosis (atherosclerotic plaque)
Clinical: develops of nighttime and early
morning (paresis, lesion of speech and over);
Atherothrombotic develops of daytime is characterized by gradual
development focal signs (watch-day).
Arterial pressure – rises slightly. Focal
symptoms depend on the localization of the
lesion and the pool.
General signs: headache, lesion of
consciousness, seizure is often absent.
History can be TIA

Etiology: develops due to the presence of

thrombotic masses in left atrium and ventricle.
The reason – for the violation heart rate,
endocarditis, disease of blood – leukemia, heart
surgery.
Cardioembolic Clinical: the sudden development of focal
symptoms, convulsive syndrome (thrombosis of
cortical branch)
Neurologic signs depend on the lesion pool and
localization a blood clot (often affects deep
cortical)
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Ischemic stroke

Develops due to the stenotic disease of

the main arteries provided a sharp drop
in blood pressure and disease of the
Hemodynamic cardiovascular system.
Clinical: neurology signs depend on the
lesion pool.
Possible:bilateral stroke in the parietal-
occipital lobe: cortical blindness,
agnosia, amnesia (middle cerebral artery
occipital)

Lacunar stroke due to pathology vessels/

the size of the stroke a few millimeters
to 1.5 sm.
Clinical: developing at any time of the
Lacunar day: due to high blood pressure.
General cerebral signs absent.
Typical focal symptoms:
- motoric syndrome
- sensoric syndrome
- sensomotoric
- atactic syndrome
- dysartria
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Stroke syndromes (occlusion of different artery)

Internal carotid Vertebral artery Basilar

artery (ICA) (VA) artery (BA)

Anterior cerebral Middle cerebral Homonimus Nonspecific

artery (ASA) artery (MCA) symptom
Hemianopsia (unsteadiness,
dysartria,
Dysarthria
Contrlateral Main trunk Posterior main headache,
hemiparesis, branch Dysphagia mental changes)
deeper in the
lower limbs Unilateral or Lesion
Contrlateral Wernicke’s bilateral limb consciousness
hemiparesis paralisis
Aphasia Tetraparesis
or hemiplegia,
Sensory deficit
Apraxia Oculomotor
Hemisensory
Ataxia disordes
deficit
Dyscalculia
Hemianopsia Lesion of
consciousness
Global
aphasia

Ischemic stroke diagnostic

1. Brain Imaging: CT or MRI
2. ECG
3. Laboratory test: complete blood count and platelet count, prothrombin time or
INR, partial thrombi time (PTT), serum electrolytes, blood glucose, C-reactive
protein (CRP) or sedimentation rate, hepatic and renal chemical analysis
4. Extracranial and transcranial Duplex/Doppler ultrasound.
5. MRA or CTA
6. Diffusion and perfusion MR or perfusion CT
7. Echocardiography (transthoracic and/or transoesophageal)
8. Chest X-ray
9. Pulse oximetry and arterial blood gas analysis
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10. Lumbar puncture

11. EEG
12. Toxicology screen

Ischemic stroke treatment

Normalization of breathing, hemodynamic, mild

epileptic status.
Regulation of water electrolytes balance: combating
edema of the brain.
General treatment Metabolic brain protection.
Prevention and treatment somatic complications
(pneumonia, thrombosis of pulmonary artery, deep
ven of lower limb, uroinfectia, bedsores).

Trombolitic therapy: intravenous rtPA (Actilyse) (0.9

mg/kg body weight, maximum 90 mg), with 10 % of
the dose given as a bolus followed by a 60-minute
infusion, is recommended within 3 hours of onset of
ischemic stroke.
Specific
treatment Anticoagulative therapy (heparini, fraxiparini and
over).

Antiagrepants: aspirini, ticlid, clopidogrel, trental.

Neuroprotection: cerebrolisins, tocopheroli and over.

Differential diagnosis
1. Hemorrhagic stroke.
2. Tumor brain.
3. Metabolic encephalopatia.
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THEMA: EPILEPSY AND NON-EPILEPTIC PAROXYSMAL STATES

Etiology 1. Idiopathic epilepsy ussually with age-related onset tends to

appear during childhood or adolescence/ there is often a family
histiry of epilepsy.
2. Symptomatic epilepsy forms result from organic brain damage:
traumatic brain injury, stroke, meningitis, multiple sclerosis,
alcoholism (one in ten alcogolic suffers from seizures), drug
addiction and many other reasons.
3. Crypyogenic form is epilepsy with undetected, hidden etiology.
Pathogenesis The basic of occurrence of spontaneous seizures is local or
generalized cortical neuronal membrane instability associated with
inherited or aacquired secondary features of metabolic processes.
Classification Generalized Partial (focal): Secondary
of epileptic seizures: Simple partial at: generalization:
seizures - tonic-clonic (grand - motor epylepsy; - start with partial
mal seizures); - sensory epylepsy; attacks a go into a
- absences (typical - visual; seazure generalized
for children); auditory;
- myoclonic; olfactory;
- akinetic guctatory;
hallucination;
- mental symptoms.
Complex partial
attacks (with the
disturbance of
consciousness)/
Diagnosis Clinical feature, EEG, MRI of brain (KT-sczn), TV-EEG-
monitoring
Differential Paroxysmal nono-epileptic states.
diagnosis
Principle Anticonvulsant therapy:
treatment Differention
Contimuty
Complexity
Individuality
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Status epileptical

Factors of status epilepticus Clinical of status:

may be:
Seizures following one another
- sudden termination at without a lucid interval is
taking antiepileptic drugs; especially dangerous tonic-clonic
epistatus.
- withdrawal syndrome;
The non epistatus: imprairment of
- sleep deprivation and consuousness randing from stupor
others to coma, may be just confusion.

Treatment
In intensive care unit: diazepam (1-2 times administration).
Control of brain edema: manitol.
Symptomatic therapy: corticosteroids, cardiovascular drugs, heperin in DIC
syndrom.
In the absense of the effect of thiopental anesthesia and over.

Paroxysmal non-epileptic states (the absence of the sourse of epileptic activity)

Convulsant Non-convulsant
Febrile and toxic seizures: Autonomic paroxysms (crises)
- hypertethermia (febrile) convulsions - autonomic dysfunction sympathy-
are typical for children temperature adrenal;
more than 380C; - vagoinsular crisis;
- seizures of infections origin (toxic) - mixed
associated with toxic-infections effects
on the nervous system (meningitis,
encephalitic).
Spasmophillia (infantile tetany). Occurs Syncope.
as a result of high peripheral - neurogenic (reflex syncope
neuromuscular excitability. vasovagal);
- cardiac syncope (paroxysmal
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supraventricular tachycardia, acute

coronary syndrome and over);
-in violation of blood homeostasis and
metabolism of the brain;
- migrane
Psychogenic nonepileptic seizures
earlier known as hystercal paroxysms.

Differential diagnosis of seizures and psychogenic seizures

Seizures Psychogenic seizures
Start at any age Does not occur in early childhood
Occurs in any conditions, even at night In the presence of the observer, doesn’t
occur at night
During the attack injury, bite of tongue Traumatic injuries are absent, but the
is possible tongue can be bitten
Attack is intermittent The long-term attack
Stereotyped synchronous movements A variety of chaotic motion. Often
accomparied by weeping, and morning
There is no resistance when doctor is Obvious resistance
trying to open the eyes of patient
Possible involuntary urination No urination disorders
Often amnesia No amnesia
Mydriasis with the lack of reaction of The reaction of pupils to light is
pupils to light preserved

Differential diagnosis of neurogenic syncope and seixures

Neurogenic syncope Seizures
Extremal factors (fear, long vertical There s no extremal factor
position)
Starts gradually Begins with aura or arises suddenly
Falling slowly, there may be some Falling is rapid
clonic jerking
After syncope the codition worsens Sleep or good condition after attack
Does not occur in a horizontal Occurs during sleep
position,during sleep
During the attack blood pressure Increased blood pressure, tachycardia,
decreases, bradycardia, pallor, sweating flushing of the skin
Epileptic activity on EEG is not Epileptic activity on EEG is detected
detected
 15

THEMA: INFECTIOUS DISEASES OF THE CENTRAL NERVOUS

SYSTEM
Meningitis
Meningitis is an acute infectious disease primarily affecting soft membranes of
the brain and spinal cord. Meningitis is usually primarily diagnosed by a general
practitioner.

Etiologic classification of meningitis

Bacterial Viral Tungi

Meningococcal Parotitic Candidal
Pneumococcal Enteroviral Protozoa
Staphylococcal
Tuberculous
Classification. According to the etiologic classification, there are the following
types of meningitis: bacterial (meningococcal, pneumococcal, staphylococcal,
tuberculous etc.); viral (parotitic, enteroviral, etc.); caused by tungi (candidal) and
protozoal.
It is practically important to divide meningitis into purulent and serous
meningitis depending on the nature of inflammation in the membranes and
contents of cerebrospinal fluid. In case of purulent meningitis it is neutrophilic
pleocytosis that is predominantly found in cerebrospinal fluid, in case of serous —
lymphocytic pleotsytosis. This classification is widely used in clinical practice.
Depending on the pathogenesis, meningitis is classified into primary and
secondary ones. Primary meningitis develops without previous general infection
or infectious lesion of any organ. Meningococcal and enteroviral meningitis
belongs to primary meningitis. Secondary meningitis occurs as a complication of
general or local infectious disease. In this case, the pathogen crosses the blood-
brain barrier and causes meningitis. Tuberculous, staphylococcal, pneumococcal
meningitis and other types of meningitis occur in such a way.
According to the clinical classification, as for the course of the disease there are
such types of meningitis: fulminant, acute, subacute, chronic, and as for the
gravity — very severe, severe, moderate and light.
There are three ways of meninges infecting: contact (perineural and lym-
phogenous) spread of the pathogen onto the meninges in case of purulent
 16

processes in the areas of paranasal sinuses, the middle ear, osteomyelitis of the
skull, direct infection of cerebrospinal fluid due to open brain or spinal injuries,
hematogenous spread of the pathogen that causes secondary purulent meningitis.
Clinical presentation of various forms of acute meningitis has much in
common. Meningitis can be suspected of basing on the combination of such
manifestations:
- syndrome of infectious disease;
- meningeal syndrome;
- syndrome of inflammatory changes in cerebrospinal fluid.

General infectious symptoms of meningitis are various. This can be fever,

general fatigue, aching pain in muscles, inflammatory changes in peripheral
blood: leukocytosis with a shift of the formula to the left, an increased erythrocyte
sedimentation rate (ESR).
In case of purulent meningitis general infectious symptoms are acutely ex-
pressed in the first hours and days of the disease. In case of tuberculous meningitis
they are expressed not acutely, gradually increasing. In patients with viral
meningitis general infectious symptoms most definitely appear in the first days of
the disease, but rapidly disappear.
Meningeal syndrome is a complex of symptoms caused by irritation or in-
flammation process in the meninges. It is observed in all types of meningitis and
consists of general cerebral and meningeal symptoms. General cerebral symptoms
include: headache, vomiting, psychomotor agitation periodically changed by
weakness, impaired consciousness, and seizures. Headaches and vomiting in a
combination with fever constitute pathognomonic triad of primary manifestations
of meningitis. Observing these symptoms, a doctor of any speciality should
suspect meningitis and check the presence of actually meningeal symptoms.
Actually meningeal symptoms are divided into general hyperesthesia and
hypersensitivity of the sense organs, reactive pain phenomena and tonic muscle
tension. Manifestations of tonic muscle tension include a stiff neck, Kernig's and
Brudzinski's signs.
The syndrome of inflammatory changes in cerebrospinal fluid is crucial in
diagnosing meningitis. In case of even a slight suspicion of meningitis a lumbar
puncture and cerebrospinal fluid analysis have to be done. According to the results
of analysis of cerebrospinal fluid, a conclusion about the clinical form of
meningitis can be made.
In patients with meningitis spinal fluid flows under high pressure and has various
coloring: serous meningitis gives a transparent opalescent colour, purulent—
cloudy, yellowish-green one. In case of purulent meningitis pleocytosis is
 17

pronounced — thousands or tens of thousands of cells in 1 mcl, mainly

neutrophils. In case of serous meningitis pleocytosis is lymphocytic, tens or
hundreds of cells in 1 mcl. If a decrease of cytosis accompanied increasing of
protein content, this may means encapsulation of the inflammation and the
formation of brain abscess.
The analysis of glucose in the contents of cerebrospinal fluid also has a great
importance. Its marked decrease is typical for tuberculous meningitis, but is also
observed in case of cronic or subacute purulent meningitis and ' meningitis caused
by fungi.
The results of cerebrospinal fluid analysis, its cellular composition, protein and
glucose level are decisive for the diagnosis and etiotropic therapy prescription. The
final etiologic diagnosis is made according to the results of bacteriological,
serological and virological analysis of cerebrospinal fluid. The inoculation of
pathogen in vital environments is also used to determine their sensitivity to
antibiotics. Immunological express methods ensure more rapid diagnostics of
meningitis etiology.

Epidemic cerebrospinal meningitis

Incubation period – 2-6 days. Disease acutely fever to 38-400C, a
Clinical sharp headache with irradiation to the neck and back, vomiting
presentation meningeal signs positive, face hemorrahic rash. Neurological
examination does not show any focal symptoms (in case of a hard
course of the disease the signs of III, IV, VII, VIII pair of cranial
nerves lesion are possible).

Cerebro-spinal fluid flows under the high pressure and has cloudy,
Diagnostic gray or yellowish-green coloring. Netrophilic pleocytosis is found
(up to tens of thousands of cells in 1 mcl), a high level of protein (up
to 1-16 g/l). In the smears of cerebrospinal fluid meningococcus is
found in 80 % of cases. It can be seen in blood smears or washout
from the posterior pharyngeal wall too.

Other forms of meningitis.

Differential Meningism at general infections (that means the absence of CSF
diagnostics changes in case of meningeal syndrome).
Subarachnoid hemorrhage (general-infection syndrome is absent,
there is no blood in CSF).

The disease lasts from 2 to 6 weeks.

Functional changes of CNS:
Prognosis
- Asthenic syndrome
- mild disorders of mental development
- focal symptoms such as paresis of extremities
- hydrocephalus, seizures, decreased vision, hearing loss,
arachnoiditis and over
 18

Secondary purulent meningitis

Pneumococcal meningitis Staphylococcal and streptococcal

meningitis

Most often the disease occurs as These rrveningites occur as

complication after pneumonia,
complication of acute and
otitus, sinusitis, mastoiditis.
chronic purulent processes or
traumatic brain injuries. The
The clinical course is hard. The onset is accompanied by
brain tissue is often affected, the chills and fever to 40°С.
picture of purulent They characterized
meningoencephalitis can be meningeal syndrome,
observed. The typical sign is loss of impaired consciousness, and
consciousness with the development
of sopor or coma, convulsions. seizures. The peculiarity of
Theie are signs of cranial nerves staphylococcal meningitis is
lesion, focal neurological symptoms frequent abscess formation,
(mono-, hemiparesis). A frequent blocking of spinal routes and
phenomenon is swelling of brain mycosis.
tissue with possible signs of
wedging. Bradycardia and low
blood pressure are observed. In the CSF cloudy, green color,
peripheral blood inflammatory netophil pleocytotis,
changes take place. increases protein, decreases
glucose, poseve -
staphylococcal
Cerebrospinal fluid is very cloudy,
has a greenish color, its pathological
changes are the same as in case of
other purulent meningitis.

Treatment
I. Etiotropic:
1. Antibiot ics: penicillinum (ampicillinum) in dose 300-400 mg per i/v or i/m;
cephalosporines, ceftriakson, cefotoxim and over 1 g 4 times per day i/v or i/m;
aminoglycozides.
The most effective are combinations of different antibiotics.
2. Sulphanilamide.
 19

3. The treatment of secondary purulent meningitis includes treatment of the source

of infection (inflammation process in lungs, middle ear and nose).
II. Pathogenetic treatment includes:
1. Treatment of intoxication (reosorbilact or reopopolyglucin)
2. Correction of cardiovascular and respiratory disturbances.
3. Struggle with cerebral edema (diuretics: mannitol, laziks and dexamethasone).
4. Heparimem doses 5000-20000 U (prevention of disseminated intravascular
coagulation).
5. Symptomatic treatment

Serous meningitis

Serous meningitis most often has viral etiology. Its pathogens can be en-
teroviruses, viruses of lymphocytic choriomeningitis, simple herpes or herpes
zoster, Epstein-Barr virus, epidemic parotiditis, tick-borne encephalitis. All of
them run with a serous inflammation of the soft cerebral membrane and are
accompanied by lymphocytic pleocytosis in cerebrospinal fluid.
 20

Tuberculosis meningitis

It occurs ill patients with hematogenic disseminated tuberculosis in case of the

presence of primary tuberculous nidus in the lungs or lymph nodes. People of all ages
may get sick, but the disease mostly affects children aged 2-7 and elderly people as
well as patients with immunodeficiency (including AIDS, alcoholism, drug abuse,
poor nutrition). The typical sign of tuberculous meningitis is the formation of miliary
tubercles in the meninges and sero-fibrinous exudate in the subarachnoid space. The
process is almost always localized on the basal surface of the brain, because the
cranial nerves are accustomed to pathological procces. The substance of the brain
itself also often suffers.

Clinical signs. Symptoms of the disease usually develop gradually. Development of meningeal
syndrome is preceded by prodromal period. Its duration can take up to 2-4 weeks. During this
period, a patient becomes weak, sleepy, and apathetic, he may have subfebril temperature. He
quickly gets tired, loses appetite and weight, has a recurrent headache. The intensity of these
symptoms increases with time, vomiting occurs. Gradually, signs of irritation of the meninges
appear: a stiff neck and long back muscles, Kernig's, Brudzinski's signs. The body temperature
increases up to 38-39 °С. With time the pathological process involves cranial nerves: oculomotor,
facial, less frequently — visual and vestibulocochlear ones. Vegetative disturbances are often
observed: excessive sweating, changes in pulse rate and blood pressure, hypothalamic disorders.
There are also focal neurological symptoms: pathological foot signs, central mono- or hemipa-
resis. The patient's condition gradually worsens, deafening proceeds, consciousness impairs,
seizures appear. Patients in bed have a characteristic meningeal posture: the head is thrown to the
back; lower limbs are bent at the knee joints.

The X-ray investigation of the lungs must be carried out. Spinal fluid is colorless with a
pearl shade and (lows under high pressure. Lymphocytic pleocytosis is found (100-500
cells in 1 mm3). The amount of glucose (up to 1-2 minol/l) and chlorides (up to 90-100
mmol/l) decreases, protein content (up to 5-10 g/l) increases. After some hours a delicate
fibrous membrane is formed in a tube with cerebrospinal fluid. A pathogen can be
detected there.

Treatment. The course of tuberculous meningitis is lengthy. Mortality reaches 10 %,

mainly among children and the elderly. In the treatment combination of three
tuberculostatic drugs is used at least: isoniazid (300-600 mg/day), rifampicin (450-600
mg), pyrazinamide (1.5-3 g/day). They all have side effects, the main one is
hepatotoxicity. In case of effective therapy after 2-3 months pyrazinamide is revoked and
treatment with isoniazid and rifampicin continues for 10-12 or more months.
 21

Enterovirus meningitis

The pathogen Clinical Epidemiology

Enteroviruses: Development acute. More common urban

Coxsackie Meningeal syndrome not residents. Children
ECHO sharply expressed. Typical aged 10 to 15 years.
general appearance of the Source of infection are
patient: against high virus carrier and sick.
temperature and hyperemia The route of infection
faces, pale nasolabial – airborne and fecal –
triangle; conjunctivitis, oral incubation periods
episcleritis, herpes rash on from 2 to 7 days
the lips and on form rash
myalgia, ataxia.

Diagnostic: CSF-lymphocytic pleocytosis, PCR-method

Differential diagnosis: over type’s meningitis, encephalitis

Treatment: bed rest, diuretics, non-steroidal anti-

inflammatory drugs, sedative drus, prednisolone and
symptomatic therapy
 22

Encephalitis

Encephalitis is an inflammatory lesion of the brain tissue of infectious or

infectious-allergic origin.

Classification

Depending on lesions In In localization: For the course:

of the brain structure depending
tissue: on the - exists stem - acute
pathogen: - cortical - subacute
- leukoencephalitis - mezencephaliti - chronic
(defeat of white - viruses c - progredient-remitting
matter) - microbial - dienenchefaliti
- encephalopathy (bacterial) c Given the neurological
(defeat to the gray (hypothalamic) clinic:
matter)
- typical
- panencephalitis
- asymptomatic
(defeat gray and
- abortive
white mater) - less frequenty
- fulmiant

Encephalitis

Primary Secondary

- arboviral encephalitis — tick-borne As a result of:

encephalitis (Russian spring-summer);
- mosquito encephalitis (Japanese, - open head injury allergies
Australian, American, West Nile); - parainfectional
- encephalitis caused by an unknown - necrotic
virus-lethargic; - gerpetic, citomegaloviruses
- herpetic; - postvaccinnal (after antirabies,
- enteroviral encephalitis (Coxsackie, antipoliomyelitic, antidiphtheric vaccine)
ECHO).
 23

Clinical symptoms of encephalitis

General infection: Cerebral: headache, Focal: depend on the

fever, chanche of blood vomiting convulsions localization process
(infamation), catarrhal psychomotor disorders,
symptoms of the upper consciousness lesion
respiratory, tract,
gastrointestinal tract.

Spring-summer (tick-borne) Epidemic encephalitis Herpetic encephalitis

encephalitis

The pathogen

Neutropic of arboviruses Unknown neurotropic In adults – herpes

virus simplex virus type 1,
newborns type 2

The route of infection

The bite of ixodes ticks or Airborne Reactivation of persistent

alimentory infection in adults sexually
transmitted from mother to
child during child birth

Pathomorphology

General process in the In acute phase of Hemorrhagic necrosis of

meninges, anterior horns of inflammation in the the medial parts of the
spinal cord; cervical part, hypothalamus, bacal nucleus, temporal and the lower plot
nuclei of the oblongata gray matter of the water the frontal lobes
brain silviera, n.oculomotorius.
Chronically degenerative
process in sybstance nigra,
pale globe.
 24

Clinical features

Tic-borne encephalitis Epidemic encephalitis Herpetic encephalitis

Acute stages: Acute stages: its duration is Clinical feature is acute

first period of fever: weeks – month or 1 year. The onset. There are cerebral
general weakness typical – Economo’s triad symptoms with
headache, myalgia includes the following: consciousness disorders,
meningeal syndrome; feverish state; oculomotor seizures and focal
second period of fever: disorders: diplopia, ptosis, symptoms: central
peripheral paresis of strabismus divergent, hemiparesis,hemianopsia,
muscles of hand neck convergence and cranial nerve lesions,
“handing head”; peripheral accommodation paralysis, violations of higher
paresis of mimic muscles paralysis of vertical gaze, cortical functions;
and bulbar syndrome. Argyle-Robertson reverse aphasia, amnesia,
Stage of recovery period of symptom; hypersomnia. There behavioral changes. The
residual effect (persistent are following autonomic disease progresses
atrophic paresis), disorders. rapidly.
Kozhevnikov epilepsy Chronic stages: parkinsonian
syndrome, hyperkinetic
syndrome, neuroendocrine
disorders.

Clinical forms spring-summer encephalitis

Acute stage: Chronic:

1. Polioencephalomyelitis (typical 1. Kozhevnikov epilepsy
form) 2. Poliomyelitis
2. Poliomyelitis 3. ALS syndrome
3. Meningeal 4. Syringomyelitis
4. Encephalitic 5. Syndrome of multiply
5. Meningoencephalitic encephalomyelitis
6. Hot well expressed
 25

Diagnosis

Spring-summer encephalitic Epidemic encephalitis Herpetic encephalitic

Epidemic anamnesis Main clinical features 1. CSF increased pressure,

(epidemic zone). Laboratory methods there lymphocytic pleocytosis
Serdogic reaction. is no specific diagnosis increased protein.
The presence of virus in blood 2. EEG. There are periodic
and CSF with its high amplitude quick waves in
indentification. temporal lobes.
3. CT and MRI scan
hypodensive zones edems,
small hemorrhages in frontal
and temporal lobes

Differential diagnosis Differential diagnosis Differential diagnosis

1. Serous meningitis 1. In the acute stage 1. Serous meningitis
2. Acute poliomyelitis meningitis serous
2. All form of
3. Tyhus 2. In the chronic stage encephalitis
with the pathology of
subcortical structure
(Parkinson syndrome)
 26

Treatment

Spring-summer Epidemic encephalitis Herpetic encephalitis

encephalitis

During three first days of Treatment of the acute Although the course
the disease serotherapy is stage include interferons of herpetic encephalitis
carried out: specific (laferon 3 mln I) or re- is extremely difficult, it
aldiron 1-3 mln U/day).
antitick-borne is one of the few
Dehydration,
immunoglobulin is detoxication, variants of encephalitis
injected intramuscularly symptomatic methods are which have a specific
in the doze of 3-6 ml 2-3 used. In case of Parkinson therapy.
times a day; prednisolone syndrome Acyclovir (Viroleks,
is injected in the dose of antiparkinsonian Zovirax) have to be
1 mg/kg. For inhibition of treatment is prescribed prescribed which
(see "Parkinson's
viral RNA replication inhibits the synthesis of
disease").
ribonuclease is injected viral DNA. The drug is
intramuscularly 30 mg 6 prescribed 15 mg/kg
times a clay during 4-5 every 8 hours
days. In addition, it is intravenously with an
important to conduct isotonic solution during
dehydration, 10-14 days. In the
detoxification, further treatment is
maintainance of fluid changed for oral
electrolyte balance. administration of the
Symptomatic therapy drug 500 mg twice a day
constitutes prescription of during 10 days. At the
anticonvulsant drugs, same time the antitoxic
anticholinesterase drugs, treatment, dehydration
vitamin therapy. and symptomatic
methods are used.
 27

Secondary encephalitis

Form Flu encephalitis Measles encephalitis

Etiology Viruses A 1, A 2, A 3 , B Severe complications of
measles
Pathomorphology Trombovascular diapeditic and Fibrous swelling of the
focal hemorrhage perivascular walls of the vessels of the
infiltrates, focal lesions of the brain. Formation prevenslik
brain foci of demyelination,
predominantly the white
matter of the brain, spinal
cord
Main clinical Hemorrhagic flu-like Encephamyelitis measles
forms encephalitis. encephalopathy
Influenzaencephalopathy
syndrome with asthenic,
vasculas autonomic syndromes
intracranial hypertension
Diagnosis Clinical symptoms of
serological and virological
studies, in CSF – lymphocytic
pleocytosis increased pressure,
the blood, protein content
increased
Differential With serious meningitis and All form of encephalitis
diagnosis encephalitis of other etiology
stroke (hemorrhagic form)
Principles of Gammo- Treatment of measles
treatment globulin,corticosteroids, neuroprotection, L-Dopa
diureticks implantation: immunosuppressants. When
etamzilat and over hyperkinesis – haloperidol,
phenibut and over
 28

Acute myelitis

Myelitis — inflammation of the spinal cord, usually exciting the white and gray
matter. Inflammation, limited in several segments, referred to as cross- myelitis.
In diffuse myelitis inflammation is localized at several levels of the spinal cord.
The disease can be caused by neurotropic viruses (enteroviruses, herpes viruses),
Bacteria (mycobacterium tuberculosis, treponema pallidum), neuioalergic
reactions during vaccination, rarely — by fungi and protista. Clinical syndrome of
acute transverse myelitis can be the first manifestation of multiple sclerosis.
Subacute necrotizing myelitis usually occurs as paraneoplastic syndrome. Almost
half the cases can not determine the cause of the disease. Frequently myelitis
inflammations are localized in the lower part of spinal cord's thoracic section.

Myelitis

The first option: the disease can be caused by neurotropic viruses

Etiology (enteroviruses, herpes viruses), bacteria (mycobacterium
tuberculosis, treponema pallidum), neuioalergic reactions during
vaccination, rarely — by fungi and protista.
The second option: develop as a complication of purulent
processes in the body: octeomyelitis, penetrating trauma, virulent
meningitis, neurosyphilis.

Pathomorphology Inflomotory process is localized in the middle or lower thoracic

departments of spinal cord.

Onset can be acute or subacute, more common in middle aged

Clinical people. Prodromal period lasts several hours or days: general –
syndromes infection signs (fever, headache) of intensive pain appears at the
level
 29

Poliomyelitis

Etiology Three strain are virus 1, 2, 3 types

Ways of infection Air-borne, alimentary ways

Forms Asymptomatic, abortive, paralitic

Clinic of paralytic poliomyelitis

STAGES

Incubation Prodromal Preperalitic Paralytic Restorative Rezidual

period period period period period
period
(1-3 days) (1-3 days) (7-10 days) (2 year)
(10-14 days)

Fever, High Perephiral Compensa- Persistent

Incubation information temperature, paresis and tion motion in after effect
period ostium, paraplegia, paresis paresis
gastro-instinal sleepiness’, spinal bulbar muscular
disorders ponds, atrophy,
meningo- deformations
radicular encephalitlc of extremities
symptoms, skeleton
cramp pain

Presence of virus in nasopharyngeal smear and fecal:,

Diagnostic defection antibody in serum blood

Isolation of patient on 6 weeks. Child (has contact of silks)

Prevention – gamaglobullini, vaccination of plans

Symptomatic, antibiotics of prevention on pneumonia,

restorative period - physiotherapy, residual period –
Treatment operative treatment.
Arachnoiditis
 30

The arachnoiditis a chronic serous inflammatory disease of sarachnoid and partly soft shell-
tunic progressive hyperplasia.
Etiology and pathogenesis: flu, sinusitis, otitis, tonsilitis, general infections (mostly child),
carried before meningitis, craniocerebral trauma and others.
Pathomorphology: thickening of the meninges, adhesions, cysts with liquid content.

Classification of cerebral arachnoiditis

Convexital Basal

Optico-chiasmatic

Posterior cranial angle

Ponto cerebellar angle

Clinical feature

More often chronic progressive Less acute Combination cerebral

and intermitten progress and focal symptoms

• Constant headache diffuse or local (forehead, back of the head). The intensity of the pain
increases in the morning.
• characteristic symptom of jump: get a headache when jumping.
• Nausea
• Vomiting
• Dizziness
• Apathy or irritability, tearfulness
• General weakness
• Rapid fatigability
• Sleep disturbance
• Can be epileptic attacks of different species

Focal symptoms depend on localization of process

 31

Convexital arachnoiditis – is symptoms of irrstation, singht sign of focal symptoms.

• focal epileptic attacks (often)

• generalized epileptic seizurs (rarely)
• asymmetry of superficial and deep reflexes
• can reduced abdominal and plantar reflexes
• the presence of pathological reflex
• light paresis of the limbs

Basal araachnoiditis charactirized by combination of cerebral and focal symptoms (focal

symptoms – signe of cranial nerve.

Optico-chiasmatic:
• headache in the area of forehead eye sockets, bridge of the nose
• the decrease in visual acuity
• loss of visual fields
• concentric narrowing of visual fieds
• congestion of the optic nerve
• anosmia (changes of sense of smell)
• vegetative disorders
• hypothalamic disorders

Arachnoiditis of pontocerebellum angle:

• headache in a cervical area

• shooting pain is in the face
• tinnitus, hearing loss
• dizziness of system character
• sometimes vomiting, ataxia

At a neurological inspection discover:

• signs of defeat of cranial nerves:

-V c.n. trigeminal neuralgia

-VI c.n. squit

-VII c.n. is peripheral paresis of mimic muscles

-VIII c.n. is a decline of ear

• to the cerebellum disorders

- ataxia
- bends or falls toward side of defeat
- nystagmus
• light pyramidal violations
- on opposite side focal sings
THEMA: AMYOTROPHIC LATERAL SCLEROSIS (ALS)
 32

Progressive neurodegerative disorders, the hallmark of which is the

destruction of central and peripheral motor neurorons. There are sporadic and
hereditary amyotrophic lateral sclerosis. Basically, the disease affect people of 50-
70 years old.

Etiology Sporadic ALS cases is unknown. In 5 percent cases, there is

an hereditary form. Exitoxic peripheral neurons and central
neurons and central neurons damage, due to increased
function of glutamate receptors.
Pathomorphologi Degenerative chages of anterior horn cells of spinal cord
(redgion cervical, lumbar segments), brain stem (nucleus
VII, IX, X, XI, XII pair of cranial nerves and nucleor paths)
and pyramidal al tracts of localization in lateral columns of
spinal cord.
Main clinical form Cerebral (high).
Bulbar.
Bulbar-spinal.
Bulbar-sacral
Diagnostic Main neurological symptoms: a combination of signs of
spastic and flaccid paresis, fasiculations of muscules a
fibrillation. Prevalence of paresis over atrophy. Additions
methods: EMG
Differential Tumor brain, spinal cord.
diagnosis Syringomyelia.
Spondilogenic cervical myelopathy.
Treatment Slowdown of disease progression therapy is the
antiglutamate drugs. The main one is riluzde (Rilutek).
Symptomatic treatment.
M-anticholinergics: acetylcholinesterase (dysartria,
disphagia).
Carbamazepine, Clonozepam, Baclofen (involuntary limbs
lerking).
Phenytoin or carbomazepin (muscle spash and pain in hands
and feet) and over.
 33

Clinical features of ALS

Typical symptoms: a combination of peripheral

and central paresis of limbs with brain stem and
supranuclear structures.

Lession anterior horns at cervical enlargment

typical: fibriller muscle twitching with gradual
atrophy of hands (arm), sholder muscles, sholder
girdle and chest, hand “monkey paw”. Pyramidal
patway is defeat alongside with peripheral motor
Bulbo-spinal form
neurons at this level hands paresis mixed: firstly
deep reflex and muscle increased present
pathologycal pyramidal reflexes sensetivity
violation and pelvic disorders are not typical

Lesion of motor nullei in medulla oblongata

dulbsr syndrome, which is clinically manifested
with dysartria, disphonia, disphagia, fibrillation
Bulbar form are observed in tongue: later atrophy of tongue
muscles occurs. Previously an increase in the
lower jaw reflex. Sometimes neck extensor
muscles weakness occurs.

The lumbar and sacral segments of the spinal

cord (lumbar enlargement) are affected. Mixed
Lumbar sacral form paresis of the legs accurs: muscle atrophy,
faciculations, hyperreflexia, pathological feet
signs. The process is ascending in nature.

Pathway from the cerebral cortex to the brain stem

structures (coorticonuclear pathways on both
sides) are affected typical: pseudobulbar syndrom,
Cerebral (high) form spastic tetraparesis. Mandibular and pharyngeal
reflex increases, reflex oral automatism apper,
violent laughing or crying may occur.
Combination pseudobulbar and bulbar syndrome.
 34

THEMA: VERTEBROGENIC DISORDERS OF THE

PERIFERAL NERVOUS SYSTEM

Vertebrogenic disorders

− Injury of vertebral body (tumor, trauma).

Etiology − Anomalies of spine
− Bone inflammation (spondilitis, coxitis).
− Degenerative changes in spine

Each intervertebral disc consists of a fibrous

ring (annulus fibrosus) and soft cartilage in the
center of the disk, which is surrounded by
annulus – nucleus pulposus.
In pathology of intervertebral discs it must be
stressed the impotance of congenital
abnormalities, age-related change; endocrine,
Pathogonesis metabolic disturbances. The effects of micro-
traumas that occurs throuhout life lead tj the
gradual drying, structural changes, reducing of
elasticity, osteoporosis and microfractures. In
response to these change the degenerative spine
disease develops in the disk locking plates in
adjacent vertebral bodies above and below/
weakned fibers of the annulus fibrosus may
rupture, allowing disk material to escape in the
annulus fibrosus, forming disk protrusion or
even beyond, forming disk herniation. Reactive
spondylosis and spondylarthrosis can develop
in this case.

Classification of vertebrogenic neurology is syndromes depending on the level

of lesion
Cervical level
I. Reflex syndromes.
1. Cervicalgia
2. Cervicocranialgia ofvertebral artery.
3. Cervicobrahialgia.
 35

II. Compressive radicular syndromes radiculopathy lesion (vertebral lesion of

roots).
III. Vascular radicular spinal syndromes (radiculoishemia, radiculomyeloishemia,
myeloishemia).
Toracic level
Reflex syndrome: toracalgia with muscular tonic, autonotic – visceral or
neurodystrophic manifestations (syndromes scapular rib, cardialgia andd over).
Compressive radicular syndrome.
Lumbosacral level
Reflex syndromes with muscular tonic, vasomotor and thropic disorders.
1. Lumbago
2. Lumbalgia
3. Lumbalishalgia
Compressive vascular radicular (radiculopathy).
Compressive vascular radicular – spinal syndrome (radiculoischemia,
radiculomyeloischemia, myeloischemia).
Nerve stretch test
Vertebrogenic disorders are often characterized by pain while palpating the
paravertebral region and by positive stretch tests:
- Lasegue’s sign (straight Leg rise). Patient is lying down on his back;
bending of leg in the coxal joint cause’s pain in the lumbar area and on course of
sciatic nerve (this is result of nervous root and sciatic nerve stretch).
- Wassermann’s sign (femoral nerve stretch test). Patient is lying down on
his stomach; unbending of leg in the coxal joint cause’s pain in the lumar area and
on the front surface of thigh (this is result of nerve root and femoral nerve stretch).
- Neri’s sign. Bending of head causes pain in the lumbar area and knee
flexing (this is a result of nerve root stretch).
 36

Neurology syndromes of vertebregic disorders of peripheral nervous system

Reflex, syndrome

Cervical level Thoracic level Lumbosacral level

Cervicalgia Cervicocranialgia Cerebrobrahialgia Thracalgia, Lumbago Lunbalgia Lumbaischalgia
dorsalgia
Acute, sybacute Syndrome Pain in muscles Pain in the chest Acute pain at Sybacute and Sybacute and
pain of neck. vertebral arterior. of neck, sholder back contractions the lumbar chronic pain chrionic pain at
The pain is Headache and arm, elboww of the thoracic level after at the lumbar the lumbar
dullaching, (temporal, and sholder muscles of the phisical level. level, that
CLINICAL SIGNS

bussting parietal region), joints, tension back, limited activities or Sensory extends to the
character pain vestibulo and limited movement due to awkward disorders buttocks, lower
increase with coxlearis, visual mobility in these pain, absence of movements, absent. limb sometimes
the movement and ear disorders. joints with sensory motor or accompanied Reflexes do both limbs but
of the head Dizziness may be possible arising reflex by a not change. does not fall on
typical drop-attack of scopulo abnormalities. significast the boot and
musculas tonic lesion level numeral constriction fingers. A
syndrome C5-C6, C6-C7, periartrosis of the back combination of
lesion of level C7-Th1. Steinbrocker muscles and muscular tonic
C4-C5, C5-C6. (shoulder hand limited and autonomic
syndrome). mobility. It – vasonotu,
lasts from neurodystrophic
several hours biolations.
to several
days.
 37

Compressive syndrome

Cervical level Thoracic level Lumbar levrl Spinal stenosis

The features: A disk herniation A feature: see the compressive Spinal stenosis is disorder that is
- signs of reflex syndromes; can compress a syndromes at the cervical caused by a narrowing of the
- seasory deficits – hypalgesia in thoracic nerve root level. spinal canal. This narrowing
the area of innervation; with sensory and Compressive syndromes at the happens as a result of the
- motor and reflex deficitis – motor deficit. These lumbar level are most degeneration of both the facet
muscular weakness and atrophy, syndromes are rare. common. Sciatica is the joints and the intervertebral
reflexes are usually markedly clinical description of pain in discs. In this condition, bone
diminished or absent; the leg that occurs due to spurs (also called osteophytes)
- autonomic disorders – skin lumbrosacral nerve root grow into the spinal canal. The
CLINICAL SIGNS

atrophy, hyperhidrosis; compression usually facet joint also enlarge as they

-electromyography reveals of secondary to lumbar disk become arthritic, which
conduction velocity of those prolapse or extrusion. L5-S1 contributes to a decrease in the
nerves, which are formed by disk level is the most common space available for the nerve
certain roots. site of disc herniation. The roots.
Nerve root C6 (intervertebral following are the There are complaints on pain in
C5-C6 foramen): pain is characteristic “lower back the buttocks, thigh or leg that
projected from neck into the syndromes” associated with develops with standing or
thumb; hypoesthesia of radial nerve root compresion. walking, and improves with rest.
foream and thumb; biceps Nerve root L4 (intervertebral In some cases, a person will
weakness, decreased or absent of L4-L5 foramen): pain and complain of leg pain and
biceps reflex. hypoesthesia on the front of weakness without having any
Nerve rooy C7 (intervertebral the thigh and the inner tibia back pain. More severe
C6-C7 foramen): pain is surfacee, weakness and symptoms include numbness,
projected intothe back surface of atrophy of the quadriceps tingling, and weakness in the
shoulder and foream to the muscle, decrease or loss of lower extremities. Certain
 38

middle finger; weakness of knee reflex. positions can alleviate the

triceps and extensor fingers Nerve root L5 (intervertebral symptoms of spinal stenosis by
muscle; decreased or absent L5-S1 foramen): pain and increasing the amount of space
triceps reflex. hypoesthesia in the buttocks, available for the nerves.
Nerve root C5 (intervertebral outer thigh surface, anterior
C4-C5 foramen): pain in the outer surface of the calf,
shoulder; weakness of the thumb; the weakness of the
deltoid, supra- and infraspinatus extensor muscles of foot and
muscles. big toe, hypotonia and muscle
hypotrophy on the front side
of shin. A patient has diffculty
to stand on the heels.
Nerve root S1 (intervertebral
S1S2 foramen): pain and
hypoesthesia in buttock, on
the outer surface of thigh, calf,
foot, little toe; weakness of
flexors of the foot and big toe;
reduced or absence of Achilles
reflex. A patient cannot stand
on toes.
 39

The diagnosis of radicular syndromes and disk herniation

X-ray of the spine at different levels to diagnose injuries, osteoporosis,

anomalies of the spine, bone changes, indirect signs of intervertebral dic
herniation.
MRI of spine and spinal cord (degenerative changes of the spine, joints,
intervertebral disc herniation, spinal cord patholology).

Conservative treatment of vertebrogenic disorders

Acute period (its duration in case of reflex syndromy is up to 3-5 days, and
in radicular syndrome it is 2 weeks).
1. Immobilisation, bed rest on hard surface, such as a film mattress or the floor.
2. Spine extension (on sloping surface).
3. Dehydration, using diuretics during 2-3 days.
4. Anaecthetic blokades (lidocaine, corticosteroids).
5. Nonsteroid antiinflammatory preperations: diclofenac, ketophrofen,
desketophrofen, ketorolac, meloxicam, nimesulide, ibuprofen.
6. Myorelaxants: baclofen, sirdalud.
7. Vitamin B complex.
8. Physiotherapy (electrophoresis, phonophoresis, laserotheraphy), local
anesthetic procedures.
9. Massage, gymnastics.
After acute period, a maximal effect has physiotherapy, massage and
gymnastics.
Chiropractic manipulation in vertebrogenic disorders is contraindicated in
patients with disk herniation, as soon as it may lead to damage of the spinal cord.
 40

THEMA: DEMYELINATING DISEASE: MULTIPLE SCLEROSIS (MS),

ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM)

Multiple sclerosis

Refers to autoimmune disease. Contemporary

conception inclyded three components which
Etiology determine the etiology of multiple sclerosis:
- viral infection
- inherited immunogenetic susceptibility
- geographic factors

It is expected to lose cells of oligoden droglia myelin

Pathogenesis sheaths, due to the formation of autoantibodies to
myelin; disintegrity myelin alters the synthesis of
glial cells.

Numerous foci of demyelination in brain and spinal

Pathomorphology cord; in place of dead cells develops gliofybrosis
(sclerotic plaques0 the common localization of
plaques lateral cords, cerebellar path of the optic.
 41

Classification MS
1. By the type of disease:

Clinical Remiting- Primary- Secondary- Progressing-

isolated relapsing progressing progressive relapsing
syndrom (CIS) (RR) (PP) (SP) (PR) MS
which may be
the first
episode of
neurological
dyfunction

Acute, PR form is PP form is SP form is

sybacute, observed in characterized characterized
isolated 90% of MS by a gradual by transition
solitary in tine patiente in steady of the RR
episode of the early progression form to the
neurology stages of the from onset progression of
disorders disease and gradual
connected characterized neurological
with one by the symptoms
(focal CIS) or relapses and with infequent
more followed by exocerbation
(multifocal complete or
CIS) foci. partial
functional
Clinical recovery in
variant: optic remission
neuritis, bain
stem
syndrome,
spinal
syndrome,
sensory
lesion. Pelvic
disorders
paroxysmal
syndrome.
 42

2. By the period of disease:

I – relapse
II – remission (first remission longer than the next)

Clinical symptoms and syndromes of multiple sclerosiis

Clinical manifestations are associated with focal lesions of brain and spinal
cord. Functional system score is used most commonly to assess the merological
manifestation. This score evaluates the severity of symptoms of various major
CNS systems.
Pyramidal tract Hemi-, para-, three- or tetraparesis. Monoparesis are
lesion observed rarely. Lower limbs suffer more likely than
upper. Spasticity may prevail over the severity of paresis
and is characterized by the restriction of active movement’s
involuntare reflex muscle spasm.
Cerebellr lesion Static and dinamic ataxia, the main manifestation of whih
symptoms. are body balance and gait disorders, dysmetria, asynergia,
muscular hypotonia.
Brain stem and Eyes movement disorders, peripheral paresis of the mimic
cranial nerve lesion muscles 9face), nystagmus trigeminal neuralgia, bulbar
disorders (dysartria, dysphagia, dysphonia).
Visual disorders Single or bilatersl decrease in visual acuty colar perception
violation; pallor of the temporal halves of optic disks,
atrophy of optic disks; occurrence of scotomas.
Sensory disorders Parasthesia and dysesthesia, deep sensetiviti disorders
(vibrative), conductive anesthesia and segmental disorders
– later stage.
Dysfunction of pelvic Disorders of urination: incontinence, imperative urgensyy
organs incontinenece, bladders emptying disorder, urine retention,
disorders of defecation and sexual dysfunction.
Mental activity The disorders of attention deterioration, memory, mood,
changes hight level of anxiety is social contracts, emotional tension.
Chronic fatigue General fatigue decrease of working copacity without
syndrome means connection with depression and muscle weakness.
Paroxysmal states Epileptic and nonepileotic origin are manifested by
seizures, autonomic visceral paroxysms, syncopes,
migraine.
 43

The specific features in multiple sclerosis

Clinical dissociation is 1. In case of externally satisfactory state of the patient and
the disrepancy of absence of movement disorders, the hyperreflexia, refuxes
dysfunction degree to are observed.
objective neurological 2. The optic disks may be changed without the clinical
status date signs of visual analyzer disturbances.

Diagnosis of MS

• Disease onset at a relatively young age.

• Polymorphism of clinical symptoms at all stages of the disease.
• Variability, “flashing” symptoms even during one day.
• There is the typecal course of the disease:
- periodic exacerbations and remissions or
- slow progression

MRI of brain and spinal cord with the compulsory contrast

injection.
MRI criteria which support MS diagnosis are reflected in
MAGNIMS Consensus Guidelines (2015) MS setting means the
dissemination of lesions in spaceat least 2 of 5 areas of CNS as
follows ≥ 3 periventricular lesions ≥ 1 intratentorial lesions ≥ 1
spinal cord lesion ≥ 1 optic nerve lesion ≥ 1 cortical lesion

Defection of DNA of pathogenes in blood:

- herpes virus type 4 (Epstein-Barrvirus) and herpes virus type 6;
- cerebrospinal fluid investigation for the presence of oligoclonal
IgG bands.

Ophthalmic research:
- optic funds: central scotoma, sectoral loss athrophia a optic disk
of visual fields and over.

McDonalds criteria
They are the most widely used criteria for evidence of “disseminztion of
lesions on plase and in time”. These criteria take into accound both the clinical
manifestations and MRI of brain and spinal cord, and presence of oligoclonal
immunoglobulin in cerebrospinal fluid.
 44

Differential diagnosis MS

Differential diagnosis MS

Autonamic vasculas
dysfunction

Acute disseminated
encephalomyelitis

Tumor brain, spinal

cord

Degenerative disease of
nervous system

Retrobulbar neuritis

Labyrinthitis
 45

Treatmen of MS

Treatmen of MS

In case of MS relapse: Symptomatic therapy: Disease – modifying

therapy:
- methylprednisolone - vitamins,
pulse therapy; antioxidants, nootropic - first-line treatment
agents, myoralaxantsm (inferon beta,
- plasmapheresis; anticholinergic drugs glatiramer acetate);
-Human and over.
- second-line
Immnnoglobulin (natalizumab
findolimed an over);
-Mitoxantrone
(antineoplastic,
immunomodulatory
agent). 333
 46

Acute disseminated encephalomyelitis (ADEM)

Etiology, ADEM is an acute imfectious and allergic disease, in which the
pathogenesis inflammatory foci of demyelization in braim and spinal cord are
observed, both white and gray matter are affected. Sheth, roots
and peripheral nerves can also be damaged. The formation of
scleroyic plagues in ADEM is possible. Adem is divided into
primary, which develops because of primary impact of fitering
virus to the nervous system, and secondary, which occurs on a
background of influenza, malaria and other acute infections. The
main feature of ADEM is the development of disse,inated
inflammation, perivascular inflitration by lymphocytes or
macrophages, or monocytes, especially around small and
medium-sized veins; perivascular demyelination is
characteristic.
Clinical features There are:
- presense of recept acute viral infection or vaccination;
- acute onset with fever and symptoms of imtoxication,
characteristic changer in peripheral blood;
- meningeal syndrome;
- neurological disorders indicated the disseminated disorders of
nervous system.
Diagnosis - Clinical picture;
- MRI data can reveal the multifocal changers in the white
matters of the cerebral hemispheres, cerebellum and brain stem;
- CSF data: a slight increase of protein content and lymphocytic
pleocytosis (up to 100 cells in 1 ml).
The courseof disease is acute and often with severe state of the
patient. After 3-4 weeks symptoms regress.
Exacerbations unlike multiple sclerosis are not observed.
Differential - Multiple sclerosis
diagnosis - Tumor brain and spinal cord
- Meningoencephalomyelitis
Treatment Acute stage: corticosteroid, antibiotics, antivirals,
antihistomines.
Recovery srage: anticholinergitic, vitamins, neurotrophic agents,
physiotherapy, massage and over.
 47

THEMA: PERIPHERAL NERVOUS SYSTEM DISEASE (PNS).

CLASSIFICATION.
POLYNEUROPATHY (GULLIAN-BARRE SYNDROME)

Classification PNS

Classification of peripheral nervous system disease

(based on anatomic principle)

Vertebrogenic injury of the peripheral nervous system

Injury of spinal roots (radiculopathy), ganglions

(ganglionitis) plexopathy.

Multiple injury of peripheral nerve, roots (acute

inferctions immunemediated, Guillian-Barre
polyneuropathy, polyneuropathy to diphtheria,
botulism, allergic, paraneoplastic, congenital
metabolic (diabetic alcoholic), polyneuropathies).

Injury of peripheral nerves (of traumatic compressive,

ishemic and inflammatory origin).

Injury of cranial nerves (nevralgia, neuropathy)

 48

Polyneuropathy
Etiology − Viral and bacterial infections.
− Tocxication (alcohol, arsenic compouds, lead, mercury and
ets).
− Iatrogenic facrors prising from the treatment with bismuth,
salts of gold, isoniazid, chemotherapy and other.
− Connective tissue disease; vasulitis and other.
− After the introduction of serums and vaccines.
− Vitamin deficiency.
− Paraneoplastic processes.
− In case of the disease of imternal organs endocrine glands,
the genetic defects.
Pathogenesis − Demyelinating polyneuropathy.
− Axonal polyneuropathy
Pathomorphology − Distal-symmetric segmental demyelination of nerve fibers.
and topic − Degenerative-dystrophic process of axial cylindrs of
peripheral nerves.
Main clinical − Polyneuropathic syndrome:
syndromes a) Peripheral distaltetraparesis
b) Disorders of sensetivity in distal parts of handsand feet
c) Pain and autonotic-throfic
− Isolated form with a primary lesion motor, sensory or
autonomic (vegetative) libers.
Diagnostic and Anamnesis, symptoms:
differencial − Eletromyograhy and nerve conduction studies (signs of
diagnostica demyelination), determinant in serum antibodies to myelin
peripheral nerve.
− With all forms of neutopathies, Raynaud’s disease, disease
with liver connective tissue, blood disease.
Principle of Plasmapgeresis, hemosorption, antiviral drugs, corticosteroids,
treatment antiholinergec, anticonul sants, vitamins B, ascorbic asid, L-
lipoic acid, antihistamines drugs, diuretics, physiotherapy,
massage.
 49

Polyneuropathy

Acute polyradiculopathy Guillain-Barre Toxic polyneuropathy Dysmetabolic polyneuropathy

General weakness Alcoholic Diabetic

Temperature rise Sensory defeat, amnesic and motor Lower vibration sense; pain, lesion
syndromes sciatic, hip, ulnar nerves, defeat
cerebral nerve V, VIII, VI; autonomic
Paresthesia lesion.
Lead
Paresis in foot’s, absent tape
Defeat motor fibers peripheral nerve and
autonomic defeat in hands Periartritis nodoses
Symptoms of strain

Lesion cranial nerves Chlorophos Gradually development neuropathy

cranial and spinocord nerves (motor,
sensor autonomic). Sings in
Defeat of sensory insignificant Headache, miosis, dysarthria, fibrillation inflammation angiopathy anothes
muscles, atrophy, increases of knee organs.
reflex
Autonomic defeat
Botulinum Hereditary form
Protein-cell dissociation in CSF

Defeat motor function from disorders Develop in of acute porphyria,

Clinical form paralysis Landouzy cranial nerves, sensory system defeat parasthesia; pain; weakness
absent muscles hands, foot; defeat of
Peripheral paralysis muscles of metabolism porphyria.
extremities, trunk, bulbar syndrome
 50

Primary polyneuropathy

Guillan-Barre syndrome (Landry’s ascendimg paralysis) – acute inflammatory

demyelinating polyradiculoneurophthy with flassid paresis sensory and autonomic
disorders.
Etiology Guillan-Barre syndrome is unknown. Cause of disease:
surgery, infection and viral disease, inflammation of the
salivary gland, malignancies, lymphoma, vaccinations,
HIV.
Immunopathogenesis This syndrome causes the dstruction, removal, or loss of the
myelin sheath of a nerve, Cuillain-Barre syndrome is
considered as acquired immune neuropathy that develops
because of pathological immune response to vaccination,
viral infectioon, ets. Autoimmune reaction against myelin
antigens of peripheral nerves leads to edema, infiltration
and lymphocytic segmental demyelination of spinal and
cranial nerves. Autoimmune reasction against axons of
peripheral nerves leads t axonal variant of syndrome (less
often).
Main clinical signs: Typical: it begins with muscle weakness and (or) sensory
Landry’s syndrome, disorders (membness) in the lower limbs, which in a few
Miller-Fisher horsers or day spread to the hands – tetraplegia. Objective
syndrome. sensory changes are minimal. Cranial nerve involvement
(III-VII and IX-XII) can be observed: fasial drop, diplopia,
dysarthria, dysphagia, oropharyngeal weakness. Pain is
most severe in shoulder girdle, back, butoks. Autonomic
nervous system involvement with dyslunction in the
sympathetic and parasympathetic system: paroxysmal
hypertension, orthostatic hypotension, tachycardia and
bradycardia, dysfunction of pelvic organs are not typical.
The Miller-Fisher type – lesion of oculomotor nerve, ataxia,
areflexia, cerebellar ar.
Current of disease The duration of the augmentation of symptons is 2-4 weeks.
A plateau phase of persistent, unchanging symptoms lasts
up to 2-4 weeks folowed by gradual symptom improvement
(3-12 month).
Diagnosis Clinical symptoms, anamnesis present, electromyography
and nerve conduction studies and albuminocytologic
dissociation in CSF, MRI (differential diagnostic).
Diffential diagnosis - Polyomuelitis
- With all forms of neuropathies
- Myelitis
- Stroke of brain steam
 51

- Myastenia
- Botulism
Treatment Maintenance of vital function.
Medical treatment: pulse-therapy with immunoglobulens,
plasmapheresis.
Symptomatic therapy: anticonvulsants, vitamina,
anticholiergic drugs, massage, electrical stimulation of
muscles (recoveri period).

Neuropathy nerve facial

Facial asymmetry

Lagophthalmos, phenomenon Bell’s, syndrome Defeat of root

“ il” nerve
Superciliary, corneal reflexes or absent lower

Peripheral paralysis

High then a chorda tympani

Disorders of taste 2/3
tongue

Disorders taste
High them a branch nerve stapedius hyperacusis

Hyperacusis

Taste hypoesthesia on 2/3

Gangl geniculi tongue

Pain of ear, herpes rash

hypoesthesia of skin ear

Decrease lacrimation
High then a nerve petrosus super, facialis xerophthalmia
 52

THEMA: PERIPHERAL NERVOUS SYSTEM DISEASE (PNS).

PlEXOPATHIES, NEUROPATHY OF UPPER AND LOWER LIMBS.
CRANIAL NEUROPATHY

Facial neuropathy
The most often primary facial nerve neuropathy is its idiopathic form Bell’s
palsy.
Main factors of The narrow bone canal in the pyramid of the temporal bone
development through which facial nerve passes.
Endogenous or exogenous factors that together provoke facial
nerve compression (tunnel syndrome).
Etiology − Local hypothermia (cord air, air conditioner)
− Of decreased immunity – activation of viruses, which persist
facial nerve ganglion HSV1, mumps virus.
− Infection (tick-bonne encephalitis lyme’s disease,
polyomyelitis).
− Inflammation of the ear.
− Face and skull traumatic injuries.
Additional causes: stroke, diabeties, arterial hypertension,
multiple sclerosis, HIV and over.
Pathogenesis In case of primary neuropathy (Bell’s palsy) as a result of above-
mentioned factors there may be edema with nerve conpression
and its ischemia, aseptic inflammation, that lead to the
development of compression-ischemic lesion with facial nerve
dysfunction.
Clinic Prosoparesis – peripheral mimic muscles paresis of the one half
symptomes of the face with facial asymmetry at rest that inclease with mimic
(main) movements.
Diagnosis - Clinical symptoms
- Electroneuromyography (EMG)
- CT-scan or MRI to defect focal lesions of the brain, which
could cause lesion of the facial nerve.
Differential Limes disease, tumor brain
diagnosis Syndrome of Ramsei Hunt’s
Syndrome Melkersson-Rosenthal
Treatment - Corticosteroids (5 day)
- Diuretic (3-5 days)
- Preparations for the improvement of microcirculation –
pentoxifylline, nicotinic acid
- Vitamin B grop.
- Acetylcholinesterase (after 10-14 days)
- Antiviral drugs (couser viruses)
- Massage, facial muscles exercises muscle toningg
 53

Trigeminal neuralgia
Etiology The most common cause is it compression for additional
influence of extra- and intracranial factors.
Extracranial: tunnel syndrome (trigeminal nerve root compression
in bone canal due to its congenital or acquired (dental, caries,
sinusitis).
Intracranial: aneurysm of basilar artery, tumor of ponto cerebelar
angle and over.
Primary (idiopatic) secondary (occurs in the backgrounde of the
main disease.
Pathogenesis It is considered that trigeminal neuralgia is caused by the
appearance of paroxysmal discharges that resemble the
mechanisms of epilepsy. Paroxysmal pain is generally thought to
be due to aberrant transmission of nerve impulse from
somatosensory to nociceptive fibers within the trigeminal nerve
in a site of local damage to myelin sheaths. The myelin lesion is
attributed to above mentioned factors or due to aging.
Clinic − Recurrent paroxysms of sharp, lancinating or stabbing pain
symptomes (electric shok type pain) that may last a few seconds or minutes.
− Pain distribution: maxillar (II) or mandibular (III) branches of
the trigeminal nerve are the most commonly affected.
− Each attack is unilateral (may aiternate sides in up to 3-5% of
cases).
− Attacks may occur as often as multiple times daily or as
infrequently as monthly, attcks become more frequent and severe
over time, attcks are very rare during sleeo.
− Some patients are sensetive in certain areas of the face, called
trigger zones, light touch or other minimal stimulation in these
zones triggers an attack. These zone are usually near the noce,
lips, eyes, ear, or inside the mouth.
− Everyday ativities can trigger an episode. Triggers of pai:
talking eating, kissing, drinking, shaving, teeth brushing, face
washing, cold explosure.
− Appeatance of fasial muscles twitching at the height of the
paroxysm – pain teak.
− Trismus – spasm of the masticatiry muscles and redused
opening of the jaws caused by trigeminal motor fibras irritation.
In period between attacks, complaints and neurological symptoms
are absent. At examination, these is pain at the exit points of the
affected branch, but no violations of sensitivsty in the area of
innervation.
Diagnosis Anamnesis and neurology status; instrumental method MRI or
CT to determine the cause of neuralgia.
Differential − Postherpetic neuralgia
 54

diagnosis − Syndrome Tolosa-Hanta

− Claster headache
− Facialis migraine
− Dental pain
Treatment − Antiepileptic drugs: carbamezepine (Finlepsin) 600-1600 mg,
gabapentin 300-2400 mg, pregabalin (Lyrica) 75-600 mg/
− Antidepressant: amitriptiline 25 mmg 3 time dayli.
− Syrgery treatment: micvascular decopression, steriotactic
syrgery.

Defeat of separate spinal nerves, plexuses

Defeat of spinal nerves, plexuses

Plexopathy Compression ischemic

Plexopathy

Brachial plexopathy

Upper brachial plexopathy Total brachial Lower brachial

(Erb-Duchenne palsy) plexopathy peripheral plexopathy (Dejerine-
damage to the upper (flassid) paralisis of Klupke palsy) damage to
primary trunk of the braxial plexus (upper lower primy trunk of the
brachial plexus formed C5- and lower) disorders of brachial plexus formed
C6 roots – disfunction of sensory, pain, autonomic of the C8-Th1 roots:
proximal limb muscles trohic disfunction of distal limb
(biceps, triceps, muscles except those,
brachioradialis musles) which are innervated by
causes their flaccid the radidal nerve.
(peripheral) paresis neck Berhard-Horner
pain, pain in proximal arm syndrome (ptosis, miosis
hypoesthesia vasomotor enophtalmos) pain
disorders. hypoethesia, vasomotor
disorders.
 55

Lumbo-sacral plexopathy plexus is formed of the L5, S1-S2 roots

Etiologia Infections, tumors of the pelvis abdomen

Flaccid paralysis of the foot, shin, thigh adductors, loss of Achilles

Clinic signs reflex, sensotr and autonomic disorders in the foot and shin.

Compression ischemic mononeuropathty

Etiology: humerus fractures, compression od the nerve

during the operation, in case of crutch using, while
Radial nerve neuropathy sleeping on arm (Saturday Night Palsy), especially after
drinking alcohol.

Clinical signs:
- writs drop that is the inability to extend the wrist upward
when the hend is palm down;
- inability to voluntary straighten the fingers or extend the
thumb;
- loss of wrist extension due to paralysis of the posterior
Upper compartment of foream muscles;
- hypoesthesia of interval between I and II metacarpal
extremities bone of hand dorsum.

Etiology: trauma

Clinical signs:
- “claw hand” – hyperextension of the IV and V
finger bend up) at the interphalangeal joints (middle
Ulnar nerve neuropathy joints);
- atrophy of hand interossei muxcles, especially in I-II
fingers;
- weakness of foream and hand elbow flexion, IV and
V finger flexion;
- sensetivity disorders in dorsal and palmar surfaces of
the V and medial aspect of IV finger, ulnar part of
hand palmar and dorsal surfaces.

Etiology: trauma

Median nerve neuropathy

Clinical signs:
- lack oa ability to abduct and oppose the thumb due to paralysis
of the thenar muscles with their atrophy, “ape-hand deformity”
forming;
- weakness of foream pronation and wrist, and in finger flexion;
- weakness of radial hand flexion and I, II, III finger flexion –
impossibility of bending of the I, II and II (partially) fingers,
“prophet hand” forming;
-froment’s sign in case of median nerve neuropathy – a patienr is
asedto hold an object, ussualy a flat object such as a piece of
paper, between their thumb and inde[ finger – in left hand
patient can hold a piece of paper only by m. adductor pollicis;
- sensory loss in the thumb, index finger, long finger, and the
radial aspect of the ring finger;
- vasimotor and thropic disorders, causalgia.
 56

Compression ischemic mononeuropathty

Etiology: hip fracture, inflammation of

the pelvis, diabetes mellitus

Femoral nerve Clinical signs:

- knee extension is impossible;
- loss of knee reflex;
- sensetivity disorder that is hypo- or
anesthesia on the inner surface of the
shin and front of thigh.

Etiology: hip fracture, inflammation of

the pelvis, diabetes mellitus

Clinical signs:
- paresis of the extensor muscles of foot
Lower extramities Peroneal nerve and finger;
- foot drop and changed gait – steppage
(gait is characterized by high lifting of
leg to put fingers first and then thr
whole foot);
- heeling is impossible;
- Achilles reflex is saved;
-sensitivity disorder that is hypo- or
anaesthesia on the external surface of
shin and dorsal surface of foot

Etiology: hip fracture, inflammation of

the pelvis, diabetes mellitus

Clinical signs:
Tibial nerve - paresis of foot and finger flexors,
impossibility of foot bending;
- unability to tiptoe;
- absence of Achilles reflex;
- atrophy of the small muscles of
foot – “claw foot”;
-sensetivity disorders: anaesthesia on
posterior surface of shin and sole;
- foot trophic disorders.
 57

Tunnel syndrome

Etiology: peripheral nerves compression in anatomical constrictions

(tunnel): rigid fibrous or muscular channels, aponeurotic holes.
There are more than 30 types of tunnel syndromes.

Etiology: transverse ligament thickening

in endocrine diseases, heavy manual
work or exposure to vibration, in case of
bursitis and tendonitis as a result of
Carpa tunnel
syndrome repeated manual motion provoke medial
nerve compresion.

Clinical signs:
- pain, numbness of I-III fingers,
enhanced while raising arm;
- Tinel’s sign – lightly tapping
(percussing) over the nerve to elicit a
sensation of tindling or “pins and
Upper needles” in the distribution of the
extremities median nerve;
- I-III finger hypoesthesia.

Compression of the ulnar nerve at the

elbow level (there is a bumh of bone on
the inner portion of the (medial
epicondyle) under which the ulnar nerve
passes).
Cubital canal
syndrome
Clinical signs:
- numbness, tingling, and pain on the ulnar
portion of the hand, V and IV fingers,
foream; interossei muscles and hypothenar
hypotrophy.
 58

Tunnel syndrome

Compression of the tibial nerve

in the tarsal tunnel. This tunnel
is found along the inner leg
behind the medial malleolus.
Tarsal tunnel
syndrome

Clinical signs:
- numbness in the foot,
radiating to the big toe and the
first 3 toes;
- pain, burning, electrical
sensations and tingling over the
Lower base of the foot and the heel,
extremities especially at walking

Bernhardt-Roth syndome,
meralgia paresthetica, derived
from the Creek word meros,
meaning thigh, and algo,
meaning pain – nerve
entrapment or compressin
Entrapment of where it passes between the
the lateral upper front hipone (ilium) and
femoral the inguinal ligament.
cutaneous nerve

Clinical signs:
- paresthesia or burning pain,
numbness in the lateral and
anterolateral thigh;
- symptoms worsen during
walking and standing.
 59

Principles of treatment of the peripheral nervous

system pathology

Corticosteroid.
Drugs improving microcirculation.
Acetylcholinesterase inhibitors.
Analgetics.
Drugs are lipoic acid diyretics.
Gabapentin.
Pregabalin.
Vitamin B grup.
Physitherapy: massage, local anasthetic blocada.
 60

THEMA: HEADACHE. CLASSIFICATION HEADACHE. MIGRAINE.

Classification of headache
1.
Migrain without aura
Migrain
Migraine with aura

Chronic migraine
Primary headache
Episodic tension type headache
Tension type
headache Probable tension type headache

Chronic tension on type

Cluster headache
Trigeminal
autonomic Hemicrania continua

Paroxysmal hemicrania

2.
Headache attributed to trauma or injury to the head and/or
neck.

Headache attributed to cranial or cervical vascular disorder

Headache attributed to non-vascular intracranial disorder

Secondary Headache attributed to a substance or its withdrawal

Headache attributed to infection

Headache attributed to disorder of homoeostasis

Headache attributed to or facial paon attributed to disorder of

the cranium, neck, eyes, nose, sinuses, teeth, mouth or other
facial or cervical structure.

Headache attributed to psychiatric disorders

3. Painful cranial neuropathies and other facial pains.

4. Other headache disorders.
 61

Migraine

Migraine is common often familial disorder characterized by unilateral throbbing

headache.
Mechanism
Mutation in mitochondrial DNA and Ca2+ channel genes may explain familial cases.
Vascular and neuronal process probably co-exist with changes in serotonin activity attacks.

Classification of migraine and complication

Migraine without aura Migraine with aura Complication of

(simple) (associated): migraine:
- ophthalmic (classical); - migrainosus
- family hemiplegic migraine; - migrainous infarction
- basilar;
- ophthamoplegic;
- retinal;
- children’s periodic
syndromes;
- migraine with the aura
without pain;
- migraine with the prolonged
aura.
 62

Diagnostic criteria migraine

Migraine without aura Migraine with aura

− At least five attacks. − At least two attacks.

− Headache attacks last 4-72 hours − Aura consist of visual, sensory andor
(without treatment or ineffective peechlanguage symptoms, each fully
treatment). reversible.
− Headache has at least two of the − At least two of the following four
following characteristics: characteristics:
- pulsating quality; - at least one aura symptoms
- unilateral location; spreads gradually over 5 5 minutes,
- moderate or severe pain intensity; and/or two or more symptoms
- aggravation by or causing occur in succession;
avoidance of routine physical - each individual aura symptom
activity . lasts 5-60 minutes;
− During headache at least one of the - at least one aura symptom is
following: unilateral;
- nausea and/or vomiting; - the aura is accompanid,

Migraine complication

Status migrainosus is a Migrainous infraction. One or Migraine aura-

gruelling migraine attack more migraine aura symptoms are triggered seizure – a
lasting for more then 72 associated with an ischaemic seizure is triggered
hours. brain lesion in the appropriate with an attack of
Occurs in a patient with area, demonstrated by migraine with aura.
migraine without aura neuroimaging. The seizure occurs
and/or migraine with aura Occur in a patient with migraine within 1 hour afte
and typical of previous with aura and previous aura the migraine attack.
attacks, except its duration description is typical, except the
and severity: unremitting fact that one or more aura
for> 72 hours; pain and/or symptoms persists for more than
associated symptoms are > 60 minutes.
d bilit ti N i i d t t
 63

Treatment of migraine

Abortion of already developed attack Prevention the attacks treatment

1. Analgetics and non-steroid This drugs are used only in frequent

antiiflammatory drugs: paracetamol, (2-3 attacks per month) and severe
ibuprofen, nsproxen, solpadein, migraine attacks duration of attacks
sedalgin-neo and over. 10-12 hours.
1. Beta-blockers (metoprolol,
2. Ergotamin-containing drugs: propranolol).
dihydroergotamine mesylate, 2. Calcium channel blockers
ergotamin, nomygreni. (nimodepine (nimotop)).
3. Anticonvulsants (topiromate)
3. Specific therapy – “triptans” –
4. Antidepressants (paroxetine, prozac
serotonin receptor type 5-
hydroxytryptamin 1 agonists: and over).
sumatriptan, eletriptan, zolmitriptan,
frovatriptan, naratriptan.
Symptoms therapy: reglan,
metoclopramide ositron and over.

Status migrainous. Severe paroxysmal migraine or a continuous series of maigraine attacks

lasting more then three days.
Clinical signs. In diffuse intense cephalgia, more than 3 days, does not regress after sleep.
General weakness adynamia, pale skin, vomiting, photophobia, hyperacusia. Possible spasm and
meningeal sundrome, general cerebral signs, change of consciousness transient visual diorders.
Status migraine can threat the development of stroke (lacunar stroke).
Diagnostic: neurology status, ophtalmoscopia, CT scan, MPI of brain, CSF.
Differential diagnosis: corticosteroids (prednisolone, dexametasone), ergotamine drugs,
antidepressants, tranqullizers and over.
 64

CLUSTER HEADACHE

Pathogenesis

Disorders of simpatico Disorders of serotonin Disorders of regulation of the

innervation on side of the pain metabolism neuroendocrinology

Course

Episodic headache Chronic headache

Flare (2-6 weeks) Remission (14 days) Remission absent or lesses

14 days

Diagnostic criterions

1. Cyclic aggravation – series of attacks cephalgia and remission on extent of months or years.
2. Vegetative signs.
3. Men ill more often age 30-40.
4. Psychomotor excitation.
5. Provoke of pain – alcohol, nitroglycerine, histamine.
6. Attacks of pain – rate at night.

Treatment

Preventive Treatment of attacks

- sanolomigrain - sumatripten
- potassium carbonate -ergotamine

- calcium channel blockers - prednisolone

- trentale
 65

HEADACHE OF TENSION

Патогенез
PATHOGENESIS

Chronic emotional stress, depressive disorders

Lesion of function limbic-brain structure

Tension of pericranial musculas

Vasospasm

Oedema and ischemia

FORMS

Episodic 30" 7-15 days on year Chronic 15-180 days on year

Diagnostic criterions

1.
1. Локалізація
Localization болю:
of pain:двобічний, дифузний.
bilateral, diffusion.
2. Character of pain: moderate, compression, pulsate pain absent.
2.
3. Характер болю: монотонний, давлючий, ниючий, не буває пульсуючим.
Intensity: moderate.
4. Signs a epiphenomenon: sickness, photophobia, cardioalgia, artralgia, tremor of finger, pain of
3. Інтенсивність: помірний, не порушає фізичної активності.
palpation, tention of temporal, occipital muscular of neck signs at VSD.
4. Супутні симптоми:
5. Beginning нудота,
at age of 20-30 years.фотофобія, фонофобія, кардалгії, артралгії без об'єктивних
ознак; тремтіння пальців, болючість при пальпації, напруження скроневих, потиличних
м'язів шиї, іпохондричний, депресивний настрій, прояви ВСД.

Treatment

Antidepressants, aspirin, diclophenac, miorelacsants (sirdalud, midocalm),

tranquilizer
 66

Ubusuna headache

Ubusuna headache – drug headache, one the secondaru forms of headache associated
with migraine. This headache manifested by bilateral, pressing or constricting naturemof
maderate intensity.
Pain when patients abuse pain medications (at least 15 days per month for 3 month or
more) worries from 15 days or more up to daily.
The basis of the busal headache is the presence of migraine. Abusson pain often causes
analgetics, NSAIDs, ergotamine drugs, tritan, and opioids.

FORMS OF PARAHYPNOSIS (DISOMNIYA)

Forms of disorders parahypnosis

Insomnia Parasomnias (somnambulism Hypersomnia

Difficulty to Rote wake up Narcolepsy Lethargy

get sleep

The syndrome of intracranial hypotension

Etiology, pathogenetis Therapeutic and diagnostic intervention on the liquor system,liquory

factors fistula with likoria.
Violation of water-salt metabolism (frequent vomiting, diarrhea, forced
diuresis). The decreased production of cerebrospinal fluid (after a
traumatic brain injury, due to autonomic dysregulation, vascular
sclerosis of choroidal plexus blood.
Arterial hypotesia.
Subjective data. Headache, often compressive character.
The desire to lower your head down.
Nausea or vomiting. Gneral weakness.
Clinical and Meningeal symptoms (sometimes)/
istrumental data Sparing the head position.
research methods. The reduced pressure at lumbar puncture.
Strengthening of all symptoms in a vertical position and a decrease in
lying, while lowering the head.
 67

The syndrome of intracranial hypertension

Etiology . The reduction in Reactive of brain Complication of Increace in production Difficulty in outflow
Pathogenesis intracranial spase edema venous outflow of liquor of liquor from the
(hemotoma, abscesses ventricular system of
and over tumor) tne brain (occlusive
hydrocephalia)
Subjective data Headache (expander
nature) of the pain Vomiting, nausea Dizziness (not a permanent syndrome)
whwn moving
eyeballs.
Clinical data Lesion of granial
nerves (more often Change of pulse, breathing and other visceral Disorders of consciousness with severe
than VI pair cranial vegetative disorders. hypertension (inhibition sopor, come).
nerve.
Data of instrumental The expansion of the The pressure increase in luncture. Change of X--Ray of Stagnant discs of the
research methods ventricular complex tj Protein-cellular dissociation in CSF. skill: optic nerves
the EchoEg and CT- - increased digital (ophthalmoscopy).
scan impressions;
- Turkish saddle;
- increased vascular
pattern;
- rashotte joints in
children.
 THEMA: NEUROLOGICAL ASPECTS OF ACQUIRED IMMUNE
DEFICIENCY SYNDROME (AIDS)

AIDS – the final stage of infection, which is human caused by the

immunodeficiency virus (HIV) and occurs with the defeat of all organs and human
systems; already in the early stage affected by the central nervous system and peripheral
nervous system.

NeuroAIDS

AIDS virus refers to human, non-oncogenic

retroviruses, which violates the immune system is
Etiology capable of persistence in the body, has a long
inclubation period has tropism to macrophages,
lymphocytes and nerve tissue cells.

Clinical and morphological data of neuro-AIDS show

Pathogenesis the primary (direct) damage to the nervous system and
numerous neurology complications, due to infections
and neoplasms (tumor ) whose occurrence is associated
with a deep suppression of immunity in patiens.

1. Early neuro-AIDS.
Classification
2. Data neuro-AIDS
 69
The main clinical forms of early neuro-AIDS

Chronic encephalitis.
Morphology – sybstrate – lesion white matter of cerebral
hemispheres, inflammatory and demielinating nature.
Characteristic signs:
- behavior changes
AIDS-dementia - cognitive-mnestic disorders
(HIV- - movement disorders
encephalopathy) MRI – diffuse cortex atrophy with subarachnoid spase and
brain ventricles extension sybcortical faci in the frontal and
parital lobes.
EEG – chenges at an early stage may be absent, at a later
stage-diffuse changes in the form of slowwing EEG activity.
CSF – lymphocytic pleocytosis.

The meningitis diagnosis is based on the presence of three

common syndromes: general infections, meningeal syndrome
HIV-associated inflammatory changes in the CSF. However atypical variant
meningitis of HIV-associated meningitis are observed in most cases.
Seizures, disorders of consiouness, mental disorders –
observed in case of severe meningoencephalitis. Diagnostic of
meningitis: lymhocytic pleocytosis, icreaced of protein, HIV-
infection and atibodies to it in CSF, while their absence in
blood is possible.

In case of neuro-AIDS virus-inducad brain and spinal cord

vasculitis development is possible. Therefore, 20% of
Vascular neuro- patients may experience a stroke. HIV-infected patient have
AIDS vascular wall infiltration with leukocytes, edema and
proliferative changes of the internal layer. This leads to
vascular obstructions, thrombosis with subsequent
development of cerebral infraction, blood vessels rupture
with hemorrhage occurrence.
 70

The main clinical forms of early neuro-AIDS

It may be isolated or combined with AIDS dementia. It is

characterized demyelization and spongy degeneration by
changes of spinal cord, in white matter (lateral and posterior
fuciculus) level thoracica (middle of and lower).
Characteristic signs:
HIV-associated -slowly progressive spastic paraparesis;
vacuolar - sensetive ataxia;
myelopathy - conductive type sensetivity lesion;
- central type pelvic organs disorders.
Neurology signs may by simmetric or asymmetricaly.
MRI-atrophy and stretch enhanced in T2-weighted mode at
thoracic level of the spinal cord imolving the cervical level or
not.

It occur at any stage of HIV-infection:

- numness, burning, parasthesia in the lower limbs that
Peripheral HIV- stregthen by the slightest touch;
neuropathy - pain inrease at night and is reduction when putting the lower
(distal, sensory limbs in cold water is typical;
polyneuropthy), - type lesion of sensoryy: glows and “socks” hypoesthesia,
antiretroviral vibration sensetivity is decreased and ruduction of Achilles
toxic neuropathy refles occurs.
Clinical signs distal sensory polyneuropathy and antiretroviral
toxic neuropathy silimar and differentiate them very diffucult.

EMG signs acsonal sensory polyneuropathy

 71

Late neuro-AIDS

Progressive multifocal encephaopathy with sybcortical

hyperkinesis and progressive dementia (headache, aphasia,
dementia, paresis, lesion of sensory, epileptic seizures.

Toxoplasmosis, encephalitis , headache, desorietation,

confusion, aphasia, cranial neurophy, hemiparesis, optical
lesions, sensory and coordinate disorders.
CT scan or MPI-data and detection of Toxoplasmosis, DNA
in blood and CSF – PCR.

Cryptococcus meningitis, headache, fever, nausea,

photophobia, confusion, weightt loss.
CSF – lumphocytic pleocytosis, increase protein decreased
glucose.

Herpetic encephalitis.
Early stage: meningeal type.
Clinical manifestations.
Stabilization stage.
Symptoms regression stage.
CSF lymphocytic pleocytosis, high IgG and positive PCR to
herpes simplex viruses are defected.

Vasculitis and cerebral circulation lesion necrotic vasculitis

is localized in the medial parts of temporal lobe; aggression
negativism, seizures are characteristic, intracerebral and
dsubarachnoid hemorrhage.

Neoplasms of the CNS.

Primary: lymphoma.
The variety of clinical symptoms is determined by the
process location.
Typical are confusion, stupor decreased memory, behavior
disorders cranial nerve lesions, hemiparesis, aphasia and
seures.
 72

Clinical HIV infection in children

HIV in early childhood contributes to the physical and psychomotor development. Recurrent
bacterial infections are marked more often in children than in adults; lymphoid pneumonitis,
pulmonary lymph nodes increase, encephalopathy and anemia are also common.
A common cause of infant mortality in case of HIV infection is hemorrhagic syndrome as a
result of severe thrombocytopenia.
The disease in children who have get HIV from their mothers during pregnancy or in the
perinatal perid proceeds considerably more difficult and rapidly progressive than in children infected
after year of life.

Treatment of neuro-AIDS and diagnosis

Neuro-AIDS treatment should be comprehensive and patthogenic. In

case of primary neuro-AIDS specific highly active antiretroiral
therapy (HAAT) prescribed which slows down the disease
progression and temporarily stabilizes the patient’s condition.
There are two groups of drugs:
- HIV reverse-transcriptase inhibitors (zidovudine, abacavir,
stavudine, etc).
- Different viral enzyme protease inhitors (indinavir, ritonavir)/
The positive clinical effect is observed in patients with neuro-AIDS
when the recombinant Interleukin-2 is added to the treatment. It
significantly improves the celluar immunity indices.
The treatment of the patients with secondary neuro-AIDS is based on
application of specific treatment of nervous system lesions caused by
opportunistic infections.

The study of neurological and neuropsychological status, EEG, MRI

and CT scan, stady of cerebrospinal fluid, imunnological reserch.
 73

THEMA: NEUROSYPHILIS
Syphilis is caused by the motile spirochaete Treponema pallidum. The natural history of
untreated infection is divided into three stages. Neurological involvement occurs in the third stage,
which is typecally many years after the initial infection. Neurosyphilis occurs in less than 10% of all
untreated cases. Penicillinsare widely used for the treatment of other infections and thus many
unsuspected cases of syphilis are treated without progressing to stages two and three.

Neurosyphilis

Etiology Infections disease of the nervous system

(Pathogen-Treponema pallidum)

Early form – lose the shells and vessls

Pathomorphology (mesenchymal reaction) late forms (ectodermal) –
lose nervous cells, fibers and glia (inflammatory –
degeherative and prolferative nature of the chages)

1. Opto-oculomotor disorders (decreased visual

General symptoms acuity, concentric narrowing of the visual fields,
symptom Argyle-Robertson, anisocoria (the
difference of the pupils ptosis).
2. Acoustic-vestibular dissociation and sympoms
of lesions of other cranial nerves.
3. Radicular syndrome (reduction loss of Achilles
and knee reflex, “radicular” pain, paresthesia and
over.

Classification neurosyphilis

Larly form Late form

− Asymptomatic meningitic − Progressive paralysis

− Acute siphilis meningitis − Tabs dorsalis
− Syphilis meningomyelitis, − Toboparalisis
meningoencrphalitis
− Meningovascular syphilis
(brain, spinal cord)
− Gummy brain and spinal cord
 74

Clinical symptoms of different form of neurosyphilis

Clinical manifestation specific no;

Asymptomatic specifiic changes in the CSF: a
meningitis lymphocytic pleocytosis increase in
protein and positive serological test.

More common in yong adult’s

Acute siphilis
clinical signs: headache, vomiting,
meningitis
nausea, meningeal syptomes. May
damage cranial nrves: III, VII, VIII,
VI pairs. CSF – lymfocytic
Larly form pleocytosis increase in protein may
be fever

Vasculitis (siphilitic) and brain and spinal

Meningovascular cord infraction. The clinical presentation
syphilis (brain and spina includes general cerebral signs, meningeal
cord sign and focal symptoms (sensory and
motor disturbances, aphasia, generalized
seizures, dusfunction of pelvic organs.

Can occur suddenly with a sharp for:

paraparalisis of lower limbs, disturbace of
trphic function (bed sores) loss of sensory,
disfunction of pelvic organs lesion of
Syphilis meningomyelitis
sheelsof spinal lumbar level
(meningoradiculitic, spinal ischemia)
pseudotabes syphilitica: occurs 1-2 year
after infection.

Localization redgion basis of brain, at

Gummy brain and spinal least in the matter of the brain. Clinical
cord signs: intracranial pressure increased.
Gummy of spinal cord most often a
single. Clinical tumor brain
 75

Clinical symptoms of different form of neurosyphilis

Progressive Developed 10-20 year after syphilis

paralysis infection. Main clinical signs are
memory and personality disturbances a
loss of acquirad skills present
symptoms Argyll-Robertson; paresis of
limms, pelvic disorders, epileptic
Late fours attacks. CSF – increaased protein,
positive Wasserman test, in CSF
lymphocyte pleocytosis.

Usually it is oberved 15-20 years after

infection.
3 clinical stages:
Tabes dorsalis Neuralgic: paraesthesia (nubness,
tingling) fist main signs – pain, it has a
lancinating character vesceral crosis;
anizocaria, bilateral pupils deformation,
Argyll-Robertson test. Decrease knee
and Achille reflexes; lesion of optic
Paralitic stage Ataxic stage nerve, oculomotor, vestibule cochlear,
trigeminal neurolgia.

Characterized by Symptoms are

severe disorders disorders of
of motor coordination in
function, the limbs and
sensetive ataxia, unstable standing
trophic and and walking
pelvic disorders, disturbance of
memory deep sensation
disturbances sensetive ataxia.
over. The muscle tonus
is decreased.
 76

Taboparalisis
Taboparalisis – combinztion of neurology symptoms of progressive psrslysis and neurology
symptoms of tabes dorsalis.

Diagnostic of neurosyphylis
− Wasseman’s positive reaction in blood and CSF.
− Positive sorological reaction immobilization paltreponemes (RIPt).
− Positive reaction Lange of CSF.
− Lumphocytic pleocytosis and protein (meningeal form).
− CT, MRI, ophtalmology.

Differential diagnosis
− Meningitis not syphilis etioligy
− Progressing disturbances of cerebral blood (vascular syphilis)
− Tumor brain (gumma brain)
− Myelitis and spinal form amyotrophic lateral sclerosis

Treatment
− Drugs that improve hemodynamics: trental acidi nicotinici
− Vitamin (group B, C)
− Neuroprotection (piracetam, gliatilin, actovegin and over)
− Symptomatic therapy

Treatment of neurosyphilis

− Basic treatment of all forms

− Penicillin of 2000000-4000000 ED – 3 weeks.
− The effective of treatment is determined according to the blood tests and CSF examination.
That’s why lumbar puncture is made just after penicillin treatment and then every 3 months.
− Symptomatic treatment: trental, nicatinici, ascorbic acid, complex b vitemis, piracetami,
physiotherapy.
 77

THEMA: HEREDITARY DISEASE OF NERVOUS SYSTEM

Hereditary diseases of nervous system

System Pyramidal Extrapyramidal Coordination

Domestic Disease Hepato- Huntin- Fried- Pier-

Clinical spastic Parckin- lenticular gton’s reich’s Marie’s
form paraplegia of son’s dystrophy chorea ataxia ataxia
Shtrumpell’s

Mainly Autosomal- Autosomal- Autoso- Autoso- Autoso-

autosomal- dominant recessive mal- mal- mal-
Type of dominant recessive dominant
dominant
inheritance

Bradicinetic Rigidity
Rigidity Trembling
Resting Rigid-
Clinical Trembling arythmokinetic
Mixed Extrapyramidal
form Cortical
Abdominal

Lower Bradikinetic- Muscularrigid Chorea Cerebellum Cerebellum

spastic and sensetiv ataxia
paraparesis ragidtrembling Hyperkinetic Dementia ataxia
Провідний
Dominant Pyramidal
синдром Trembling syndrome
syndromes

Miorelac Holinolytics Unitiol Neuroleptics Nootrops

Vitamine B Amantadine Cuprenile Trancvilisators Vitamine group B

Treatment Massage Inhibitors of Hepatopratec- Antidepresans Massage

MAO tion
Neuroprotection Ortopedics
Stimulators of Symptomatic treatments
Antiagre gants dophamine treatments
receptors
 78

Differentially diagnostic criteria of ataxia of Friedraich’s and Pier- Marie

Signs Ataxia of Friedraich’s Ataxia of Pier -Marie

Type of heredity Autosom-recession, very rarely - Autosomno-dominantniy

dominant
Age sick at the beginning of 6-15 years 20-40 years, middle – 34 years
disease
Character of changes of reflexes Lower High

Presence of pyramid signs Observed on the late stages of Observed already on the early
disease stages
Defeat of cranial nerves Absent Oculomotor disorders, declines
lower of visual
Presence of sensitive ataxia Observed already on the early Absent
stages
Deformations feet, spine It is practical in all of cases Not characteristic

Hereditary diseases of nervous muscular system

Progressive muscular dystrophy Paroxysmal myoplegia Myotonia

Primary Secondary
 79

Myotonia

Thomsen’s myotonia Dystrophy myotonia

Type of
Autosomal-dominant inheritance Autosomal-dominant

- myotonic spasms are localized - myotonic spasms

in the different groups of Dominant
muscles; syndromes - hands ape

- athletics type of trunk; - neuroendocrine disorders

- syndrome of big finger - hear vascular disorders

Slowly advance Advance intensive

Flow diseases

Treatment

Diphenils, diacarbs, physio-therapeutic methods

 Progressive muscular dystrophy

Primary Secondary

Pseudo Juvenile form Fasioscapulo- Spinal form Charcot- Proximal form

hypertensive form humeral mydriasis of Werdning- Kugelberg-
Клінічні
Clinical форми
forms Erb-Rott’s Marie disease
of Dyushen’s Landouzy-Dejerine Welander
Hoffman’s

Sex-linked Autosomal Autosomal Autosomal Autosomal Autosomal

recessive trait recessive dominant recessive dominant or recessive or
Type of
autosomal autosomal
inheritance
recessive dominant

First three yeas In 14-16 years In 15-20 Three forms: In 15-30 From 4 to 8
years - congenital year years,
Age sick at the
- forever
beginning
- early child’s after
sometimes
disease 15-30 years
6 monthly
- late 1.5-2.5 years

Pseudohyper- Proximal Face of Peripheral Muscle weakness in Pathological

trophy is muscle “myopat”, paresis, distal part of lower muscular
Dominant
tiredness in foot
syndrome present in some weakness’ lips are fibrillation, extremity, disorders
muscles of prominent bulbar paresis of sensory –
extremities polyneuritic type

Treatment Glucose, insulin, riboxinum, cornitin, retabolite, vitamins group B, acidi nicotini, trental, solcoseril, proserin, cocorboxlasa,
ATP, treatment – individual, complex, long.
 Myasthenia

Autoimmune diseases, hyperplasia of the thymus

Etiology

Muscles weakness, specific feature of this weakness is its increasing

with oculomotorius disorders, weakness of mimic muscles.
Clinical features
Generalized forms - heavy form, weakness of respiratory muscles.

Progressive with remission

Flow

Myasthenic crisis

Diagnosis Proserine test, phenomenon Uolker’s, CT, EMG

Differential diagnosis Guillain’s-Barre syndrome, botulism, muscles dystrophy, stroke on

tumor, encephalitis

Compensation of neuro-muscular transference, thymus influence,

Treatment correction of immune disorders, treatment conservative and surgical
 82

Myasthenic syndroms

Connected with violation exit acetylcholine from presynaptic space

Connected with violation formation acetylcholine from defeat peripheral

motoneuron

Connected with fast blockade neuromuscular transmission (neuromuscular defeat:

myopathy with myastenic componens

That appears on background swelling (tumors) and inflomations process brain

steam localization (brain, arachnoencephalitis, tumor brain steam)

Connected with hereditary neuromuscular disorders (myopathy with myostenic

components)
 83

Paroxysmal myoplegia

Type of Autosomal-dominant
inheritance

Clinical forms Classic paroxysmal myoplegia (hypokalemic, Vestphal’s diseases);

hyperkalemic (adynamia episodic a hereditary, Gamstrop’s diseases)

Dominant Weakness extremity and body, arise a surprise (in tame of sleep), reach
syndromes general plegia deep and skin reflexes is automic defeat absent

Діагностика
Diagnosis Exsame of electrolytes, wheys of blood are in the period of attack,
electromyography.

Treatment Gypokalemic form: to potassium chlorid, veroshpirons, diacarb’s, diet

(to limit the reception of carbonhydratess).
Gyperkalemic form: calcium chloride, hydrochlorothiazide

Muscular dystonia

Focal dystonia Multifocal in two Hemidystonia (for Segmental

and more not example, dystonia dystonia in two
Blepharospasm adjacent of foot and hand on segments
(blepharospasm, one side) adjacent (spasm
Mimic muscles
spasm dystonia foot’s winking, writers
spasm rotatory)
Spastic dystonia
 84

THEMA: SOMATONEUROLOGIC SYNDROME

The leading mechanisms - Toxic effect of somatic pathology and related

development metabolic disorders in the nervous system.
- Hypoxia associated with impaired oxygen supply
and metabolism in the brain.
- Pathological reflex effects of the affected organs
and tissues, which cause disorders of enzyme and
mediator activity of the nervous system

− Asthenic syndrome – of all somatic disease

− Vegetatve (autonomic) – of all somatic disease
− Polyneuropathy – avitaminosis B1, distrophya
peripheral nervous, vascular genesis, diabetis,
disease liver, kidneys, gastrointestinal tract.
− Neuromuscular disorders:
- myopathic (hyperthyroidism, throtoxicosis);
- myasthenic (thyrotoxicosis, paraneoplaxstic
processes;
Neurological syndrome - paroxysmal myoplegia\encephalopathy (in
disease of the cardiovascular system, lungs,
liver, gastrointestinal tract, pathology of
endocrine organs)
 Acthenic syndrome (neuro-psychlogical weakness)

− Fatigue and exhaustion with mood instabilite.

− The weakening of self-control.
− Intolerance.
− Sleep disorders.
Clinical signs − Loss of the long-term mental and physical stress
capacity.
− Intolerance toloud noises, bright light, sharp odor.
− Irritability and rapidly occurring exhaustion that
follows.
− Affective lability with pravalence of depressed
mood with features of pelulance and discontent.

The proper of vitamins, organization of work and

Treatment leisure, walking, regular and adequate nutrition,
sleep recovery, physical exercises should be applied.
Also the nootropic agents
 86
The syndrome of autonomic dysfunction (AD)

Clinical signs:
− Headache
− Increased irrtability
AD with predominance of − Fatigue
sympathoadrenal nervous
− Pain in the heart area
system
− Tendency to hight blood pressure
− Accelerated hearbeat
− Various neurotic reaction and states
− Constipation

Clinical signs:
− General weakness
AD with predominance of − Fatigue
parasympathetic nervous − Headache
system − Hypotension
− Bradycardia
− Dizziness, syncope
− Cardialgia
− Diarrhea

Is manifested by ache or discomfort in the heart,

The cardiac type AD feeling short of breatth on exertion, palpatations.
ECG data show functional extrasystoles? PQ
interval shortening by slowing of intraventricular
conduction, signs of ventricular repolarization
dysfunction.

Spontaneous, sporadic, intense period of anxiety.

The duration of such an attack lasts for 20-30
minutes.
The syndroms of a panic attack:
− Pain or discomfort in the chest
Panic attacks (autonomic
− Arterial blood pressurerising
paroxysms)
− Stuffiness
− Dizzines or weakness
− Fear of death
− Fear of “going nad”
− Nausea or stomach discomfort
− Numbness or tingling
− Frequent palpations
− Shaking
The attack ends with the excessive urination.
 87

Autonomic-visceral dysfunction

Is a clinical and pathogenetic form of autonomic dysunction associated with

violations of autonomic regulation of intermal organs. The most common
manifestations of autonomic-visceral dysfunction are such functional secretory-
motor disorders of gastrointestinal tract as rritable bowel syndrome, bilary
dyskinesia, neurogenic bladder, asthma etc.

Diagnosis The presence of autonomic dysfunction symptoms requires the

exclusion of various diseases, accompanied by dysfunction of
autonomic nervous system. Laboratory and instrumental methods of
examination are conducted to diagnose the somatic function.

Prevention and treatment of autonomic dysfunction should begin in childhood. It has

already been proved, that the autonomic dysfunction that begins in children or
teenagers, can become an unfavorable background of many disease in abults.
Treatment The treatment if autonomic dysfunction is conducted againts a background of the basic
therapy that lead to it. Herewith day regime optimization is recommended: night sleep –
at least 8-10 hours, daily walks – 2-3 hours, limited television watching and computer
work to 1,5 hours, morning exercises.
Nutrition for patients with sympathicotonia should consist of meals with sait content
restriction, exclusion of spices, coffee, tea, chocolat, whereas in case of a vagotonia
these products can be included into the diet.
Physiotherapy place an important role in the tratment of autonomic dysfunction. In case
of sympathicotonia electric sleep, music and aromatherapy, baths with a decoction of
pine and melissa or mint, buble baths, shower, massage of neck area by a calming
technique, followed by electrophoresis of sodium bromide are used.
Also sedative therapy (tincture or extract of valeriana root, melissa, motherwort,
solutions of bromine), nootropic agents (sedative, antidepresants).
In patient with sympathicotonia, antihypertensive drugs are prescribed: β-blokers,
diuretics.
Patients with vagotonia undergo courses of treatment with ginseng tincture,
Eleutherococcus, Shizandra Chinese, aralia, Levzei, Beresh drops.

Syndrome of polyneuropathy
Syndrome of polyneuropathy is a multiple lesion of the distal regions of peripheral nerves
(see topic: peripheral nerve)/ it is observe in infection (influenza, diphtheria), intoxications (alcohol,
lead, etc.), metabolic disorders (diabetes mellitus, etc), avitaminosis.
Depending on the affected tunks of peripheral nerves (autonomic, sensory, motor),
polyneuropathy is characterized by pain, numbness in the limbs, sensetivity disturbances by the
type of “glover” and “socks”, weakness and hypotonia of muscles in distal parts of arms and legs
accordingly.
The therapy is based on treating the main disease, also vitamin B complex, antichlinergic
agents, massage, physical therapy, exercise therapy are used.
 88

The syndrome of neuromuscular disorders

In the majority of cases is the symmetrical, painless and slowly progressive

Myopathic sydrome muscle lesion in proximal parts of extremities.

− Motor impairments, which are manifested by muscle weakness: the

reduce of force and range of the active movements.
− The absence of sensitivity violations.
Clinical signs
− Muscle atrophy often occurs.

− Occurs in paraneoplastic processes, particularly in bronchogenic cancer

(Lambert-Eaton myasthenic syndrome).
− Botulism (botulinum toxin penetrates the nerve endings through
Myasthenic syndrome presynaptic membrane and cleaves proteins that participate in the release
of acetylcholine in the synaptic cleft), at treatment with aminoglycoside
antibiotics. While using penitsyllamid D can cause the block of
postsynaptic membrane potential.

The tratment involves medications that promote the release of acetylcholine

from the nerve terminals of neuromuscular connections – guanidine chloride
Treatment (20-50 mg/kg/day) and amiridin (1 mg/kg/day). In myasthenic syndrome
occuring due tj the use penicillamin D, anticholinergic medications are used
(neostigmine, pyridostigmine).

Is characterized by recuring paralysis of the limbs.

During the attack of myoplegia, the muscle tone is reduced, tendon reflexes
disappear, the muscles do not respond to mechanical and electrophysiological
Syndrome of paroxysmal stimulation.
myoplegia The syndrome is the result of endocrine disorders: hyperthyroidism, Conn
disease (primary hyperaldosteronism), Addison disease and other.
The pathogenesis of paroxysmal myoplegia is associated with decreased levels
of potassium and sodium metabolic disorders.

Is a global brain dysfunction due to a variety of different organic and inorganic

Encephalopathy causes. It is divided into hepatic encephalopathy, hypoxic- ischemic, neonatal,
syndrome uremic, acute hypertension, chronic traumatic, toxic encephalopathy, etc.:
Lyme disease (borreliosis), Hashimoto’s Encepfalopathy.

Neurological symptoms are loss of cognitive function, personality changes,

inability to concentrate, lethargy, and syncope.
Clinical signs Other neurological symptoms may include myoclonus (involuntary twitching
of a muscle or group of muscles), nystagmus, tremor, seizures, agitation, and
respiratory disorders, such as breathing with apnea, Cheyne-Stokes breathing,
posthypercapnia apnea.

The therapy of encephalopathy syndrome involves the use of memantine –

Treatment the antagonist of glutamate N-methyl-D-asparate (NMDA) receptors,
inhibiting glutamatergic neurotransmission and progression of
neurodegenerative processes. Cholinesterase inhibitors in brain are used
(donepezil, rivastigmine); they block te disintegration of acetylcholine, whch
transmits neural excitation in the CNS. Also nootropic agents are used.
 89

THEMA: CEREBRAL PALSY

(INFANT CEREBRAL PALSY)
Etiology Pathology of intrauterine development (during pregnancy
pathology, diseases of the mother, intoxication,
immunological incompatibility between mother and fetus)
and mechanical factors.

Pathogenesis and Fetal brain hypoxia; presence of embryonic cells in the

pathomorphology cortex, areas of softening, caveties with glial cells, necrosis in
the subcortical nodes, various anomalies odf development.

Mzin clinical Pyramidal (paresis, paralysis).

syndromes Extrapyramidal (various variants of hyperkinesis).
Myscular dystonic.
Cerebellum.
Intellectual disability.

Clinical forms Hemiplegic, tetraplegic.

Little.
Cerebellum.
Hyperkinetic.

Diagnostic Clinic signs, anamnesis, MRI, CT-scan of brain.

Treatment Medical gumnastics.

Balneotherapy and mud therapy.
Nootropics.
Holinoloki.
Agonists and antagonists.
Muscle relaxants.
Ascular therapyy.
 90

THEMA: SHEMA OF STUDY OF PATIENS WITH A NEUROLOGIST

Interview Passport detalis, a patient’s complaint, anamnesis of the disease,
anamnesis of life

Objective research General status: Neurologic status:

− appearance of the patients; − state of conciousness;
− of the skin integument; − cranial nerves;
− of the osseous joint system; − sensitivity;
− respiratory system; − system of involun tary
− cardiovascular system; movements;
− digestive system; − cordination and statics;
− genitaurinary system; − vegetative system
− endocrine and metabolic (autonomic);
system − higher nervous activity;
− psyche.
Additional Laboratory: general clinical, biochemical, immunological
research studies, muscle biopsy.
Instrumental: electroencephalography, echo-encephalography,
doplerography.
Radiography of the skeel and spine MRI, CT, angiography,
myelography, ofthalmoscopy.

Summary of − differential diagnosis

neurological − topical diagnosis
status: − presumptive clinical diagnosis
− definitive clinical diagnosis
− prevention methods
− assessment of disability
 91

INDEX OF DRUGS TO COMMON NEUROLOGICAL DISEASE

1. Neuroprotectors.
1.1. Antioxidants: vitamin E, ascorbic acid, emoxipin, cytoflavin, actavegin.
1.2. Antiglutamate: riluzole, lamictal, resemiden.
1.3. Calcium antagonist: nimotop, cinnarizine, stegeron, flunnarizine.
1.4. Brain metabolism enhancers: nootropics, instenon, cerebrolysin, preperations
Ginkgo biloba, glyatilin, glycinum.

2. Brain hemodinamic enhancer.

2.1. Thrombolytics: actilyse.
2.2. Atiplateletagents: clopidogrel, ticlid, trental, agapurin, acetil solycicylis acid.
2.3. Anticoagulants: heparin, clexan, fraxiparin, xarelto, pradaxa.
2.4. Vasoactive drugs: nicergoline (sermion), vincamine, vinpocetin (cavintion),
nimotop, betagistin.
2.5. Angioprotectors: ditsinon, rutin, troxevasin.

3. Means improving and stabilizing liquor circulation:

3.1. Corticosteroids: predisone, dexamethasone.
3.2. Venotonic: eufillin, detralex, phlebodia.
3.3. Saluretics: lasix, diacarb.

4. Drugs used for Parkinson’s disease treatment.

4.1. L-DOPA containing: nacom, madopar, stalevo, sinimet.
4.2.MAO-B inhibitors: selegiline hydrochloride (Jumex, eldepryl).
4.3. Dopamine revasing from depot: amantadine, neomidantan.
4.4. Dopamine agonists: mirapex, bromkriptin.

5. Antiepileptic drugs:
5.1. Valprov acid: depakine chrono, convulex retard
casbozepine: finlepsin, finlepsin retard, tegretol
lamotrigine: lamictal
topiramate: topamax
levetiracetamun: keppra
barbiturates: benzonal, phenobarbital.
5.2. Agents for stopping a series of convulsive seizures or status epipticus: sibason,
ralanium, diazepam, barbiturates (Sodium Thiopental).

6. Drugs used for treting migraine headaches tj relieve an attack:

 92

6.1. Ergotamine preparation: dihydroergotamine.

6.2. Agonist serotonin: sumatriptan, zolmitriptan.
6.3.Anticovulsants: finlepsin, tegretol.
For the prevention of freguent attacks:
6.4. Agonist serotonin: sandomigran.
6.5. Calcium antagonist: B-blockers, L-blokers, nicergoline, cinnarizine, nimotop,
propranolol, bisoprolol.

7. Vegetotropic: drugs that stabilize autonomic activity.

7.1. L-blockers: sermion, pyroxane.
7.2. B-blockers: propranolol, bisoprolol.
7.3. Antidepressants: amitriptyline, mirtazapine, venlafaxine, prozac, zoloft, melitor,
rexetin.
7.4. Tranguillizer/anxiolytics: diazepam, noophen (phembuti).
7.5. Herbal adaptogenes: agents containing, Rhodiola resea, Valerian root, Ginselg,
Eleutherococcus, Aralia, Giger and other.

8. Agents used in neuromuscular conduction: acetylcholinesterase inhibitors (AchEI),

proserinum, lalymin, galantamine, nevalin, neostigmine.
8.2. Contributing to myelin recovery; vitamine gr.B, lipoic acid drugs: berlition,
dialipone, espalipon, phosphaden, lecitin, neurotransmitter acids.
8.3. Improves muscle metabolism: vitamine B, retabolid, aminoacid complex.
8.4. Antiglutamate in motor neuron diseases: relutec.

9. Drugs used in autoimmune and demyelinating diseases of nervous system.

9.1. Corticosteroids: prednsolone, metypred, soluped, solumedrol, dexamethasone.
9.2. Cytostatics: azathioprine, imuran.
9.3. Antihistamine: mavegil, suprastin, peritol and over.
9.4. Immunomodulators: timaline, t-activin.
9.5. Preventive therapy MS: interferons: rebit, avonex, beta-1a; betaferon – beta 1b.

10. Antiviral drugs: valtrex, zovirax, acyclovir.

11. Treatment of pain.

11.1. Non-steroidal anti-inflammatory drugs: diclofenac, meloxicam, mavalis,
nimesil, ibuprofen and other.
11.2. Antispastic drugs: mydocalm, sirdalud, baclofen, katadolon, miorix, disport.
11.3. Neuropatic pain: gabapentine ( febantin, neuralgin), pregabolin: lyrica.
 93

11.4. Antidepressants: amitriptyline, mirtazapine, venlafaxine, prozac, zoloft, melitor,

rexetin.

12. Drugs used in Myasthenia gravis: acetylcholinesterase inhibitors, kalymin,

proserini galantamine, nivalin, potassium: kalii orotas, kaldyum, immuneglobulin:
octagam; corticosteroids: pednisolone.

13. Lipid-lowering drugs: atorvastatin (Atoris), lovastatin (Lovacor).

13.1. Provastatin (Lipostat), rosuvastatin (crestor).
13.2. Nicotinic acid drugs.

14. Antihypertensive drugs:

14.1. ACEinhibitors: captopril, enalapril, lisinopril.
14.2. Diuretics: thiazide: hypothiazide, indopamide; potassium-sparing: veroshpiron,
inspra, spironolactone; loop diuretics: furosedide, lasix; selective Beta-blockers:
atenolol, esmolol, bisoprolole; calcium channel blockers: amlodipine; angiotensin 2
antagonists: valcasor, micardis.

15. Hypnatics drugs: melatonin, zopiclon, zolpidem and otheres.

16. Neuroleptics: aminasine, haloperidol, droperidol, eglonil (sulpiride).

17. Antistress: magneB6, persen, gerbestress, befren and other.

 94

TESTS

1. First-line treatment for epilepsy is valproate. What drug belongs to this

pharmacological group?
A. Cavinton.
B. Betaserc.
C. Noophen.
D. *Depakine.
E. Tegretol.

2. Specify the anti-epileptic drug.

A. Cerebrolysin.
B. Tanakan.
C. *Lamotrigine.
D. Cavinton.
E. Warfarin.

3. Which of the folowing drug is used tj treat Myasthenia gravis?

A. Lucetam.
B. Depakine.
C. *Kalymin.
D. Topiramat.
E. Clexane.

4. Antriviral drug should be prescribed in case of herper ganglionitis. Specify it.

A. Kalymin.
B. Clexane.
C. *Valtrex.
D. Lamotrigine.
E. Rosuvastatin.

5. A 35-year-old patient complained of attacks that had started with parethesia in the
left extremities. Then he lost consciousness, bit his tongue, tonic-clonic seizures and
involuntary urination appeared, then he fell asleep. He was prescribed
anticonvulsants, but ceased to take them suddenly, which caused tonic-clonic
seizures, followed one another repeatedly in short time. What treatment is applied
first?
A. General anesthesia.
B. Decongestant drugs.
 95

C. *Antiepileptic drugs.
D. Corticosteroids.
E. Lumbar puncture.

6. A 7-year-old schoolboy was inattentive during lessons, smacking movements of

lips his appeared. During the brief attacks, he was not responding to his name, the
falling and seizures were not observed at that time. His mother had noticed such
events before, but ignored them, considering that the child was fooling around. What
is the most likely epilepsy form?
A. *Absence.
B. Generalized myoclonic attack.
C. Adversive seizure.
D. Complex partial sizure.
E. Simple motor seizure.

7. A 45-year-old patient adressed to the doctor complaining of intermitte spasmodic

muscle twitching of his arms, similar to electric shock, which lasted about 1 sec. what
is the most likely diagnosis?
A. Myoclonic absences.
B. Syncope.
C. Vasovagal paroxysm.
D. *Neurotic condition.
E. Simple absences.

8. Name the type of cerebral circulation disorders, which is characterized the

meningeal syndrome and absence of neurological deficit:
A. Small-vessel occusion (lacune).
B. Transient ischemic attack.
C. Cardioembolic ischemic stroke.
D. *Acute hypertensive encephalopathy.
E. Progressive vascular leukoencephalopathy.

9. Name cerebral artery, which lesion can lead to alternating paralysis:

A. Internal carotid artery.
B. *Basilar artery.
C. Middle cerebral artery
D. Posterior cerebral artery.
E. Anterior cerebral artery.
 96

10. Name the signs of ischemic stroke in the blood supplying area of the right middle
cerebral artery:
A. *Left-side hemiplegia.
B. Alternating paralysis.
C. Visual agnosia.
D. Motor aphasia.
E. Dysarthria.

11. Indicate changes of cerebrospinal fluid in case of subarachnoid hemorrhage:

A. Transparent color.
B. *Erythrocytes in CSF.
C. Normal pressure of CSF.
D. Lymphocytic pleocytosis.
E. Expresses neurotrophilic pleocytosis.

12. Name the instrumental method for diagnosis of brain aneurysm:

A. Cerebrospinal fluid exam.
B. CT scan.
C. Ultrasound reserch of vessels.
D. *Angiography.
E. Dopplerography.

13. A 57-year-old patient with high blood pressure (220/120 mm Hg), facial flushig,
palpations, severe sweating was admitted to the neurological department.
Objectively: strained frequent pulse, excessive urination; stiff neck, Kernig’s
symptom. Focal neurologic symptoms weren’t observed. There were no signs of
brain damage on CT scan. What is the priliminary diagnosis?
A. Hemorrhagic stroke.
B. Transient ischemic attack.
C. *Acute hypertension encephalopathy.
D. Ischemic stroke.
E. Hypertensive crisis.

14. Migraine with aura is:

A. *Recurrent attacks ofunilateral fully reversible visual, sensory or other central
nervous system symptoms followed y headache lasting.
B. Reccurent headaches manifested in attacks lasting 4-72 hours.
C. Symptoms associated with an isvhemic brain lesion in the appropriate area.
D. Seizure triggered with an attack of migraine.
 97

E. Attacks of momentary pain, occurring with great frequency and responding to

indomethacin therapy.

15. Status Migrainosus is:

A. Recurent headaches manifested in attack lasting 4-72 hours.
B. Symptoms associated with an ischaemic brain lesion in the appropriate area.
C. *Gruelling migraine attack lasting for more than 72 hours.
D. Seizure triggered with an attack of migraine.
E. Attacks of momentary pain, occurring with great frequency and responding to
indomethacin therapy.

16. Treatment of tension-type headache:

A. Beta-blockers.
B. Caicium channel blockers.
C. Triptans.
D. *Antidepressants.
E. Anticonvulsants.

17. What are the main factors of insomnia?

A. Response to stress, mental phenomena.
B. Alcohol, drugs.
C. Pain phenomena.
D. Hunger, noise, light.
E. *All answers are correct.

18. Intrasomnia is:

A. *Frequent night awakenings.
B. Difficulties falling asleep.
C. Sleep disorders with fast chaging of time zones (jet lag).
D. Somnambulism.
E. Syndrome of sleep period deceleration.

19. Narcolepsy is:

A. Lack of sleep.
B. Decreased duration of sleep.
C. Sleep phase distortion.
D. *Excessive sleepiness during the day.
E. A large number of dreams.
 98

20. During the examination of a patient with influenza the meningeal syndrome was
marked, but no inflammatory changes in the cerebrospinal fluid were detected. Which
diagnosis is most likely?
A. *Meningismus
B. Purulent meninitis.
C. Serous meningitis.
D. Tubercolous meningitis
E. Armstrong’s meningitis.

21. A patient has fever, muscle pain, gastrointestinal disorders and herpetic rash on
the lips, herpetic sore throat. Meningeal symptoms are positive.CSF: pleicytosis (92%
of limfocytes). Which diagnosis is the most likely?
A. Meningismus.
B. Purulent meningitis.
C. *Serous meningitis caused by Coxsackievirus and ECHO
D. Tuberculoos meningitis.
E. Armstrong’s meningitis.

22. A patient has had general exhaustion, pallor, anorexia, drow siness, weakness,
irritability, tearfulness that lasted for 2 weeks. Later nausea, headache, constipation,
neck muscle stiffness, Kernig’s and Brudzinski’s sign strabismus and mydriasis
appeared. CSF: pleocytosis (80% limphocytes, 20% neutrophilis). Which diagnosis is
most likely?
A. Purulent menigitis.
B. *Tubercolous meningitis.
C. Serous meningitis.
D. Meningismus.
E. Armstrong’s meningitis.

23. A patient came back from Siberia a few days ago and could not raise his hands
up, in sides, flex, and extend the arm in elbows, his head haangs down, neck muscles
were weak, dysarthria and dysphagia were marked. Detect the most appropriate
diagnosis.
A. *Tick-borne encephalitis, poliomyelitic form.
B. Tick-borne encephalitis, meningeal form.
C. Tick-borne encephalitis,meningoencephalitic form.
D. Ponto-cerebellar angle arachnoiditis.
E. Posterior fossa arachnoiditis.
 99

24. A patient had fever for 3 after which diplopia, ptosis, strabismus divergent,
acoomodation paralysis appeared, cannot sleep at night and feels sleepy during the
day. Which diagnosis is the most appropriate?
A. Economo’s epidemic encephalitis, vestibulo-ataxic form.
B. Economo’s epidemic encephalitis, hyperkinetic form
C. *Economo’s epidemic encephalitis, oculolethargic form.
D. Tick-borne encephalitis, meningeal form.
E. Tick-borne encephalitis, meningoencephalitic form.

25. A patient hasmeningeal syndrome, pain while pressing the eyeballs, trigeminal
points and points of occipital nerves outcome, symptoms of III, VI, VII pairs of
cranial nerves disorders, pathological reflexes and speech disorders. Anamnesis: had
influenza a few weeks ago. CSF: bloody, high pressure, high protein content. Which
diagnosis is the most appropriate?
A. Postvaccinal encephalitis
B. Parainfectious encephalitis.
C. *Influenza encephalopathy.
D. Rheumatic encephalitis.
E. Economo’s epidemic encephalitis.

26. A child has severe headache, vomiting, twitching of muscles, horizontaal

nystagmus, meningeal symptoms, but there is no paralysis. Anamnesis: a week ago
he visited his friend with fever. CSF data: lymfhocytic pleocytosis, slight increase of
protein. Which diagnosis is the most appropriate?
A. *Poliomyelitis, meningeal form.
B. Poliomyelitis, insidious form.
C. Poliomyelitis, abortive form.
D. Poliomyelitis, paralytic form.
E. Poliomyelitis, encephalitic form.

27. A patient had fever, chills, malaise for 2 days, then moderate pain and paresthesia
in the lowers limbs, back and chest, motor, sensory and pelvic disorders appeared.
St.neurological: spastic tetraparesis, respiratory disorders. Conductive hypesthesia
from the C3 level. Which diagnosis is the most appropriate?
A. *Myelitis of upper cervical level of the spinal cord.
B. Myelitis of cervical enlargement level of spinal cord.
C. Myelitis of thoracic level of the spinal cord.
D. Myelitis of lumbar level of the spinal cord.
E. Myelitis of half of the spinal cord.
 100

28. A patient had fever, chils, malaise for 3 days, then flaccid paresis of lower limbs
appreared, which changed on the spastic tetraparesis with bulbar syndrome, disorders
of breathing in a few days. Which diagnosis is the most appropriate?
A. Subucate necrotizing myelitis.
B. Myelitis of upper cervical level of the spinal cord.
C. * Myelitis of cervical enlargement level of spinal cord.
D. Myelitis of thoracic level of the spinal cord.
E. Myelitis of lumbar level of the spinal cord.

29. What changes in the cerebrospinal fluid in syphilitic meningititis are no marked?
A. *Albuminocytologic dissociation.
B. Neutrophilic pleocytosis.
C. Lymphocytic pleocytosis.
D. Direct Argyll Robertsom symptom.
E. Increased pressure.

30. Name the symptom, which is characterize the absence of direct and consensual
reaction of pupils to light while preserving their reaction to convergence and
accommodation.
A. Claude-Bernard-Horner syndrome
B. *Reverse Argyll-Robertson symptome
C. Direct Argyll-Robertson symptom
D. Brudzinski sign
E. Foster-Kennedy syndrome

31. Patient suffering from neurosyphilis has ataxia due to the damaged of following
nervous system structure.
A. Pyramidal pathway
B. Anterir horns of spinal cord
C. Lateral columns of spinal cord
D. *Dorsal columns of spinal cord
E. Flechsig’s and Gower’s pathways

32. Progressive paralysis is characterized by:

A. Depression
B. Dementia
C. Antisocial behavior
D. Changes in personality
 101

E. *All answers are correct

33. A 29-year-old patient was diagnosed with brain tumor on MRI examination. In
anamnesis: freguent infections resistant to treatment, generalized candidosis. Blood
analysis: lymphopenia. What form neuro-AIDS can be diagnosed?
A. AIDS-dementia
B. Primary neuro-AIDS
C. *Secondary neuro-AIDS
D. HIV-associated vacuolar myelopathy
E. HIV-associated meningitis

34. A 25-year-old patient was hospitalized with mnestic disorders. General status:
reducad memory, apathy, loss of interest to communicate with other, poor emotional
expressions. No motor and sensory disorders. Doctor suspect neuro-AIDS because of
positive test detecting antibodies to the HIV antigens. What form can it be suspected
first of all?
A. *AIDS-dementia
B. Vascular neuro-AIDS
C. Progressive multifocal encephalopathy
D. HIV-associated vacuolar myelopathy
E. CNS Tumors

35. A 25-year-old patient was hospitalized with HIV-associated meningitis. What

treatment will you apply in primary neuro-AIDS?
A. Corticosteroids
B. Immunosuppressive drugs
C. *Antiretroviral therapy
D. Treatment of opportunistic infections
E. Neuroprotection.

36. A 31-year-old patient has unsteadiness at walking, weakness of limbs, urinary

retention. She has miltiple sclerosis for 8 years with periodic exacerbations in autumn
annualy and remissions with recovery to the previous neurological symptoms after
exacerbation. Neurological status: mild central tetraparesis, cerebelar ataxia, urinary
retention. What clinical type of MS does the patient have?
A. Stable
B. Primary-progressive
C. Secondary-progressive
D. *Remitig-relapsing
 102

E. Relapsing-progressive.

37. Corticosteroid therapy in patients with multiple sclerosis primarily reduces:

A. *Duration of exacerbation
B. Limb spasticity
C. Loss of vision
D. Permanent weakness
E. Sexual dysfunction.

38. In a 41-year-old male patient, a week after acute tonsillitis, weakness in the legs
was revealed, two days after – weakness in the arms and intercostal muscles, a day
after – swallowing difficuties. Neurological status: frequent and superficial
respiration; pharyngeal reflex is absent, the hyolaryngeal excursion decrease, flaccid
tetraparesis, reduced of all kinds of sensetivity like stocking & glove distribution.
What is the most likely diagnosis?
A. Multiple sclerosis.
B. Asthenic syndrome
C. *Acute inflammatory demyelinating polyradiculoneuropathy
D. Cervical myelopathy
E. Diphtheritic neuropathy

39. The main clinical signs of polyneuropathy:

A. *Symmetric and diffuse lesions of the peripheral nervous system.
B. Multiple lesions of peripheral nerves
C. Headache and fatigue
D. Diffuse lesions of the peripheral nervous system
E. Damage of cranial nerves.

40. A 54-year-old male patient with chronic alcoholism complains of pain in feet and
calves, burning feelings in feet and hands, gait imbalance, especially in the darkness.
Neurological status: lack of tendon reflexes, hypoesthesia “socks” and “gloves| type,
deep sensitivity disorders, sensitive ataxia. What is the course of ataxia?
A. Cerebellum degeneration
B. Poliomyelitis
C. *Damage of proprioceptive fibers
D. Multiple sclerosis
E. Damage of spinal cord posterior columns.
 103

41. A 35-year-old patient has a strong burning pain on the skin of the chest after
herpetic eruptions that took plase month ago. Neurological status: pain while pressing
the paravertebral points in the thoracic region, sensitivity disorders in the form of
annular strips on the body surface. What is the most likely diagnosis?
A. *Postherpetic neuralgia.
B. Herpetic ganglionitis
C. Thoracalgia
D. Spinal cord tumor
E. Thoracic radiculopathy.

42. A 23-year-old female patient was sitting in the train at the open window. In the
morning patient could not close the right eye; her right mouth angle dropped down,
the food was stuck between the right cheek and gum. Neurological status: asymmetry
of the face, right nasolabial fold is smoothed, the right eye is wider than the left,
eyewatering on the right side, the right eyebrow does not rise. Taste is saved. What is
the most likely diagnosis?
A. *Bell’s palsy
B. Pontocerebellar angle tumor
C. Brainstem stroke
D. Facial myositis
E. Brainstem tumor

43. A 33-year-old male patient after falling on the left shoulder complained of pain in
the left subclavian area, weakness and movement limitation in the distal left arm.
Neurological status: atrophy of the left hand muscles, violations of sensitivity on
inner surface of hand and foream. What is the most likele diagnosis?
A. *Traumatic brachial plexopathy C7-Th1
B. Thoracic radiculopathy
C. Defeat of the cervical spinal cord C7-Th1
D. Traumatic brachial plexopathy C5-C6
E. Hematomyelia

44.A 24-year-old male patient has traumatic injury of the right clavicle and shoulder
joint. His complaints are a sharp pain in supraclavicular area and right upper limb
while examining it was found the decrease of muscle tone and strength, reflexes loss,
decrease of all kinds of sensitivity on the right arm. What is the most likely
diagnosis?
A. Traumatic neuropathy of right median nerve
B. Hematomyelia
 104

C. *Right-sided traumatic brachial plexopathy

D. Traumatic neutopathy of right radial nerve
E. Traumatic neuropathy of right ulnar nerve

45. A 42-year-old patient has the pain and hypoesthesia on the front of the left thigh
and the inner tibia surface, weakness and atrophy of the quadricepts muscle, decrease
of knee reflex. Which nerve root compression is characterizes by these symptoms?
A. L2
B. *L4
C. L5
D. S1
E. Th12

46. Specify the ojaective symptom, which is notrefer to stretch tests:

A. Lasegue’s sign
B. Wassermann’s signs
C. *Babinski’s sign
D. Neri’s sign

47. Reflex syndromes at the cervical level are not characrerized by the next features:
A. Barre-Lieou syndrome
B. Forced head and neck position
C. Neck pain, painful spasms and neck muscles terntion
D. *Sensory, motor and reflex (changed reflexes) disorders
E. Absence of sensory, motor and reflex (changed reflexes) disorders

48. Syringomyelia is based on the formation of _______in the spinal cord:

A. Tumor
B. Cysts
C. Absceses
D. *Cavities
E. Haemorrhages

49. “Syringomyelitic” sensory disorders:

A. * “Jacket type” of the sensory loss
B. Stocking & glove distribution
C. Hemianalgesia
D. Parestesias
E. Tactile hallucinations
 105

50. What are the main signs for the formulation of diagnosis “Cerebral palsy”?
A. *Movement disorders
B. Mental disorders
C. Spech disorders
D. Autonomic dysfunction syndrome
E. Seizures

51. Which form of speech disorders does not occue in children with “Cerebral
Palsy”?
A. Detayed speech development
B. Dysarthria
C. *Aphasia
D. Alalia
E. Speech disorders due to the reduced of intelligence

52. What change in the heart rhythm is the most common cause of cardioembolic
stroke?
A. Paroxysmal tachycardia
B. Long Q-T syndrom
C. Bradycardia
D. *Artial fibrillation
E. Adams-Stokes syndrome

53. A 36-year-old patient complains of the pain and paresthesia in the legs.
Neurological examination detected the los of deep sensitivity, sensitive ataxia, and
lower spastic paraparesis. Patient suffers from the Addison-Birmer’s disease. What
structurea are mainly affected in this case?
A. Only lateral columns of the spinal cord.
B. Peripheral nerves
C. Anterior columns of the spinal cord.
D. Posterior and then lateral columns of the spinal cord.
E. Brain stem

54. A 67-year-old patient has small cell lung carcinoma. He complains of the
proximal muscles weakness, feel difficulty when walkin, it is difficult to climbstairs,
some increase of muscle strength after exercises is characteristic. On the rhythmic
electrical stimulation of motor nerve a phenomenon of “increment” is detected. Name
syndrome.
 106

A. Adams-Stokes syndrome
B. Addison-Birmer syndrome
C. *Lambert-Eaton syndrome
D. Myopathic syndrome
E. Paroxysmal myoplegia

55. Myasthenic syndrome occurs in case of:

A. *Bronchgenic cancer
B. Fibromyoma
C. Leukemia
D. Kaposi sarcoma
E. Ischemic stroke

56. Name clinical signs of myopathic syndrome.

A. Sensetivity violation
B. *Motor impairments
C. Ataxia
D. Oculumotor disorders
E. Seizures

57. A 43-year-old patient complains of numbness and weakness in the legs after long
walk. Neurological status: feet are cold tj the touch, stocking & glove distribution
sensitivity disorders. Achilles reflexes are desreased, pathological reflxes are ansent.
Name the neurological sendrome.
A. Myasthenic syndrome
B. *Polyneuropathy
C. Myelopathy
D. Encephalopathy
E. Radicular

58. A 26-year-old patient complains of the weakness and fatigue in the muscles of
feet. Neurological status: gait with high lifting of legs (steppage), standing on heels is
impossible. Hypotrophy of affected muscles changes legs in the form of “invertwd
bottle” or “stork legs” what nerve innervates affected muscles in this disease?
A. Tibial
B. Femoral
C. *Peroneal
D. Sciatic
E. Sural
 107

59. A 20-year-old patient complains of the weakness and fatigue in the muscles of the
pelvic and shoulder girdle, problems while walking, getting up off the floor in some
stages, helping himself with his hands. Symptoms slowly progress since 15 years.
Neurological status: atrophy of proximal muscle groups of the pelvic and shoulder
girdle, the symptoms of “free shouders”, “duck march”. Reflexes are reduced.
Pseudohypertrophy is absent. What is the most likely diagnosis?
A. Duchenne muscular dystrophy
B. *Erb’s muscular dystrophy
C. Facioscapulohmeral muscular dystrophy (Landouzy-Dejerine type)
D. Neural muscular atrophy (Charcot-Marie-Tooth desease)
E. Muscular atphy type III

60. A 29-year-old patient has been suffering from weakness in the calf and feet
muscles while walking for 4 yers, as well as pain while standing at thr same place for
a long time. Neurological status: paresis of extensors of feet, achille raflexes are
absent, walking on heels is impossible. What is the most likely diagnosis?
A. Duchenne muscular dystrophy
B. Juvenile scapulohumeral mucscular dystrophy (Erb’s type)
C. Facioscapulohumeral muscular dystrophy (Landouzy-Dejerine type)
D. *Neural muscular atrophy (Charcot-Marie-Tooth desease)
E. Muscular atrophy type III
61. A 23-year-old patient complains of slow motion in his lower limbs and fatigue
during fast walking. Neurological status: tendon hyperreflexia, pathological refles,
ankle and knee clonus. Strumpell’s spastic psraplegia is suspected. What clinical
feature is the most important for this diagnosis?
A. *Prevalence of spasticity over paresis
B. Pathological reflexes
C. Ankle clonus
D. Knee clonus
E. All mentioned

62. Patient complains of tremor in right hand and leg. Neurological examination:
bradykinesia and hypokinesia, hypomimia, bradylalia, muscle rigidity, unilateral
tremor of “rolling pills”, which disappears or is reduced during movement. What
drugs are contraindicated for this patient?
A. Substitution therapy by levodopa drugs
B. *Haloperidol
C. Monoamine oxidase B inhibitor
 108

D. Dopamine agonists
E. NMDA-receptor antagonists

63. A 62 year-old patient complains of one-sided ptosis and diplopia, weakness of the
extremities. In the morning the patient feels better, symptoms are reduced after rest.
Tests on muscle fatigue and Waker’s phenomenon are positive. What is your
preliminary diagnosis?
A. *Myasthenia gravis
B. Lambert-Eaton syndrome
C. Botulism
D. Intracranial tumor
E. Paroxysmal myoplegia
 109

A QUESTION IS FOR THE VERBAL QUESTIONING

Infectious nervous diseases:

- Classification of meningiis of cerebrospinal fluid

- What type of dissociation CSF with meningitis?
- What are clinical symptoms characteristic of meningitis?
- What research needs to be done when meningitis is suspected?
- What meningitis is characterized by the reduction in the amount of glucose in the
CSF?
- What syndromes characteristic of encephalitis?
- What focal symptoms characteristic of acute stage of epidemic encephalitis?
- What symptoms characteristic of chronic forms of epidemic encephalitis?
- What focal symptoms characteristic of acute stage of spring-summer (tick-borne)
encephalitis?
- What clinical symptoms characterized of chronic ctage tick-borne encephalitic?
- What clinical symptoms of brain abscess?
- What diseasses should be differentiated from brain abscess?
- What forms of nervous system involvement in HIV-involvement?
- What forms of nervous sytem in herpetic infections?
- What classification and clinical symptoms of disiae Cretzfeldt Jacob.
Demyelinating disiase:

- What forms of multiple sclerosis?

- What are the options of the disiase of multiple sclerosis?
- What brain structures are more affected in multiple sclerosis?
- What are the early sings of multiple sclerosis?
- Clinical signs Charcot triad.
Amytrophic lateral sclerosis:
- What structures of the nervous system most affected in amyotrophic lateral
sclerosis?
- What clinical signs of amyotrophic lateral sclerosis?
- What are the causes of death in amyotrophic lateral sclerosis?
- What treaatment of amyotrophic lateral sclerosis?
Acute desseminate encephalomyelitis
- What clinical signs of encephalomyelitis?
- Differencial diagnostics of multiple sclerosis and acute dessominate
encephalomyelitis
- What methods diagnostic of demyelinating disease?
 110

Desiase of peripheral nervous system

- Classification peripheral nervous system.
- Unlike reflectory in radicular syndromes.
- List of reflectory vertebrogenic syndromes of cervical, thoracic and lumar levels.
- Feature polyneurities syndrome (polyneuropathy).
- Types neuropathy in the etiology and pathogenesis.
- Acute demyelinatingpolyradiculoneuropathy of Guillain-Barre, clinical forms.
- Ischemic compression syndromes of upper, lower limbs, clinical signs
- Braxial plexitis, clinical signs of different types.
- Clinical features of neuropathy of the facial nerve.
- Treatment of neuralgia and neuropathy of cranial nerves.
Traumatic defeat of nervous system

- What forms of closed craniocerebral and spinal trauma?

- What symptoms of brain concussion?
- What symptoms of brain contusion?
- What symptoms of traumatic hematoms?
Perinatal lesion of the nervous system
- Resk factors of perinatal pathology of nervous system.
- Infantile cerebral palsy, clinical forms.
Neurosis and somatoneurology
- Classification of neuroses.
- What symptoms of neurosthenia, hysteria.
- Classification of somatoneurology syndromes.
- Sings of nervous system disorders in various somatic disease.
Cerebral vascular disease
- Classification of vascular diseases.
- Sings of transient ischemic attacks.
- TIA diagnostic and treatment principles.
- Brain sroke: ischemic, hemorragic.
- What symptoms of intracerebral of hemorragic strok.
- What symptoms of subarachnoid hemorrahage.
- Ischemic stroke diagnostics.
- Ischemic stroke treatment.
- Subarachnoid hemorrahage treatment.
- What classification of headache?
- Vascular type of headache.
- Tension headache.
- Migraine, pathogenesis.
 111

- Clinical forms of migraine.

- Treatment of migraine.
- Cluster headache.
Brain and spinal cord tumors
- Classification of brain tumors.
- Charasteristics of some brain tumors.
- Clinical signs of brain tumors.
- Diagnostic of tumor.
- What changes in the cerebrospinal fluid with brain tumors.
Epilepsy
- What classification of epilepsy.
- Characteristics of pathogenesis of epilepsy.
- Idiopathic forms of epilepsy of symptomatic epilepsy.
- Clinical characteristic of epileptic seizures.
- Status epilepticus.
- Diagnostics of epilepsy.
- Treatment of epilepsy.
- Tretment of status epileptics.
- What nonepileptic paroxysmal states.
Hereditary diseases disorders of nervous system
- Classification of hereditary diseases/
- What are clinical signs primary, muscular dystrophy:landouzy-Dejerine, Erb
limb-giral, Duchenne?
- What are the clinical signs of secondary muscular dystrophy: Werdnig-Hoffman,
Kugelberg-Welanders, Charcot-Marrie-Tooth.
- What additional methods of examination necessary for diagnosis muscular
dystrophy?
- Treatment muscular dystrophy.
- What are clinical signs of Parkinsons disiase? Treatment.
- What are the clinical signs of Huntington disease?
- What are the clinical signs Wilson-Konovalov disiase?
- What are the clinical signs of Friedreich’ disease?
- What are the clinical signs Pierre Marie’s disease?
Syringomyelia, craniocervical junction
- What structures are affected in syringomyelia?
- What forms of syringomyelia?
- What are the clinical signs of syringomyelia?
- What abnormalities of the craniocerebral junction development you know?
Neurosyphilis
 112

- Classification of neurosyphilis.
- What are the symptoms of syphilis, meningitis?
- What are the signs of meningovascular syphilis?
Clinical pharmacology of drugs used in neurology
- Which groups of drugs in neurology:
Neuroprotection
Diuretics
Glucocorticaids
Antibiotics
Vegetotropona
 113

RECOMMENDED LITERATURE
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Stuttgart : Thieme, 2004. - 440 p.
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Hanley @ Belfus, 2000. - 228 p.
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Campbell. - India : Lippincott Williams & Wilkins, 2013. - 818 p.

Additional
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Biller. - 5th ed. - Philadelphia : Lippincott Williams & Wilkins, 2007. - 422 p.
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Wilkins, 2005. - 232 p.
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/ J. Burks, K. Johnson. - Demos Medical Publishing, 2000. - 598 p.
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6. Compston A. McAlpine's Multiple Sclerosis / A. Compston, I. R. McDonald, J.

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Factor, W. J. Weiner. - New York: Demos Medical Publishin, 2002. - 180 p.
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A. Stanley, M. Hallett. - 2nd ed. - Elsevier, 2011. - 556 p.
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New York : J. B. Lippincott, 2002. - 363 p.
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1306 p.
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Simon [et al.]. - 5th ed. - New York: Lange Medical Books; McGraw-Hill, 2002.
— 390 p.
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- 3th ed. - W.B. Saunders, 2011. - 916 p.
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- Lippincott Williams & Wilkins, 2008. - 768 p.
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Steiner. - Springer Press, 2011. - 760 p.
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Mowzoon, K. Fleming. - Informa Healthcare, 2007. - 1003 p.
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20.Nolte J. The Human Brain: An Introduction to Its Functional Anatomy / J. Nolte.

- 6,h ed. - Philadelphia (PA): Mosby; Elsevier, 2009. - 720 p.
21.Panayiotopoulos C. P. The Epilepsies. Seizures, Syndromes, and Management /
C. P. Panayiotopoulos. - Bladon Medical Publishing, 2005. 190 p.
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Springer-Verlag, 2005. - 452 p.
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Philadelphia : Lippincott Williams & Wilkins, 2000. -180 p.
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Whitley, M. Marra. - 3,d ed. - Lippincott Williams & Wilkins, 2004. - 960 p.
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2008. - 319 p.
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Informational resources

1. Department nervous disease ZSMU. – URL : http://www.doc.zsmu.edu.ua

2. Standards of medical care in neurology. - URL : http://neurology.com.ua/
3. standarty-okazaniya-medicinskoj-pomoshhi-po-specia
4. Міжнародний неврологічний журнал=International Neurological Journal. -
URL : http://www.mif-ua.com/archive/mezhdunarodnyij-nevrologicheskij-
zhurnal/numbers
5. Практична ангіологія-Practical Angiology. - URL: http://angiology.com.ua/
6. en-site-page-about
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