Ministry of Public Health of Ukraine Ukrainian Medical Stomatological Academy

Approved At the meeting of the department of neurological diseases with neurosurgery and medical genetic "__"______20___ Protocol №______Head of department ______prof. Delva M.Yu.

METHODICAL INSTRUCTIONS FOR THE INDEPENDENT WORK OF STUDENTS FOR PREPARATION TO PRACTICAL CLASSES AND DURING PRACTICAL CLASSES

Educational General medical practice discipline The module № 2 Neurology, including neurostomatology Employment theme Vascular diseases of the brain Course IV Faculty Foreign Students Training (stomatological)

Poltava 20___

1. Relevance of the topic. The problem of cerebrovascular pathology is of great scientific, practical and social importance. Among the causes of death throughout the population, acute cerebrovascular accident ranks third. Most acute cerebrovascular accidents occur against the background of existing chronic cerebral circulatory disorders. Most patients remain disabled. Recently, more patients of younger age have been observed. Vascular diseases of the brain require competent diagnostics, skillful use of paraclinical study methods, and modern approaches to therapy. Timely detection of cerebral vascular crisis and stroke, as well as conducting emergency care in the early hours of the development of these diseases can save the patient's life and work capacity. Early detection of initial brain circulation disorders and their causes can prevent vascular events in the future. Therefore, knowledge of the topic is essential for doctors of all specialties.

2. Specific objectives: 1. To elicit from anamnestic data collected from the patient the information indicative of the cerebral vascular disease. 2. To draft the individual scheme of diagnostic search. 3. To find out the most informative features of cerebral circulation in the objective examination of the patient (neurological status), instrumental and laboratory data (blood tests, cerebrospinal fluid, TCDG, REG, Echo-EEG, ECG, CT scan, MRI of the brain). 4. To conduct differential diagnostics of different clinical forms of acute disorders of cerebral circulation (differential diagnostics between stroke and transient cerebrovascular accidents). 5. To justify and prescribe differentiated therapy. 6. To identify organizational forms of medical tactics in acute disorders of cerebral circulation (transportation, department profile). 7. To use the deontological rules of conduct in the management of patients with impaired cerebral circulation.

3. Basic knowledge and skills, needed to study the topic (interdisciplinary integration)

The preceding subjects Obtained skills Department of Internal Medicine History taking Propaedeutics To determine the required volume and Department of Normal Physiology, consistency of study techniques: Department of Internal Medicine physical, laboratory and instrumental Propaedeutics (TCDG, REG, ultrasound study of the neck vessels, EG Echo, ECG, CT, brain MRI) examination methods

Department of Radiology

To conduct physical and neurological examination of the patient Department of Internal Medicine, topical diagnosis of diseases of the nervous To evaluate the results of laboratory system and paraclinical studies

Department of Normal Physiology, Department of Internal Medicine Propaedeutics

Topical diagnosis of diseases of the To recognize neurological syndromes nervous system Department of Pathological Anatomy To interpret the morphological substrate of the brain pathology

Department of Pharmacology To use the means of medical, etiotropic, pathogenetic and symptomatic therapy

Department of Internal Medicine To assess the condition of the patient Department of Pathological Physiology with vascular pathology

4. Tasks for self-directed work when preparing for classes and during the lesson.

4.1 The list of key terms, parameters, characteristics that students must learn when preparing for classes: № Term Definition 1 Dyscirculatory Slowly progressive diffuse and focal disease of encephalopathy (DEP) the brain matter, due to chronic circulatory disorders of the brain, or episodes of acute cerebrovascular accidents 2 The initial The diagnosis is made if the patient presents the manifestations of signs of general vascular disease cerebrovascular (atherosclerosis, hypertension, vegetative- insufficiency vascular dystonia) and has at least two of the following complaints: headache, dizziness, head noises, impaired memory, decreased performance, sleep disorders, which have been noticed by the patient at least once a week during the last three months, with no signs of organic deficiency, as well as in the absence in the history of traumatic brain injury, transient cerebrovascular accidents, past infectious diseases of the brain. 3 Transient Acute disorder of cerebrovascular circulation, cerebrovascular which developed as a result of short-term local accidents cerebral ischemia; it is characterized by sudden onset of focal neurological symptoms, which persist no more than 24 hours. 4.2. Theoretical problems for the class:

Question Guidelines for training actions

1. Cerebrovascular supply To study the main vessels of the brain and the area of their blood supply in the textbook and anatomical atlas. 2. Classification of cerebral circulation disorders. To study and write down in the copybook the classification scheme of cerebral circulation 3. Etiology of cerebral disorders. circulatory disorders. To study the list of diseases and pathological conditions that can be the cause of acute and chronic 4. Pathogenesis of cerebral cerebrovascular insufficiency. circulation disorders. To study the system of pathogenetic factors in the development of acute and chronic disorders of 5. Clinical presentation of cerebral circulation. acute and chronic disorders of cerebral circulation. To formulate, systematically write down and learn the clinical signs of chronic disorders of cerebral circulation: 1. The initial manifestations of cerebral circulation 2. Encephalopathy (I, II, III degrees) 3. Transient disturbances of cerebrovascular circulation: 6. The use of paraclinical Cerebrovascular crises (hypertonic, study techniques in the hypotonic) and diagnosis of acute Transient ischemic attacks in the carotid and cerebrovascular accidents vertebrobasilar systems.

To master the features of changes: in the fundus of the eye, in the blood tests, in CSF analysis, in TCDG (transcranial dopplerography), 7. Differential diagnostics of ultrasound study of the neck vessels, REG, EEG, acute cerebrovascular Echo-EG, angiography in different clinical forms of accidents acute disorders of cerebral circulation.

By the example of examined patient, to conduct the 8. Differentiated treatment of differential diagnostics of stroke and transient acute disorders of cerebral cerebrovascular accident circulation. Using the textbook and reference book "Medicinal agents", study the principles of treatment in the initial manifestations of insufficient cerebral circulation, vascular encephalopathy (I, II, III degrees), transient cerebrovascular accidents: cerebral vascular crises (hypertonic, hypotonic) and transient ischemic attacks. To master the list, dosage and formulation of medications: dehydrating (antiedematous) antihypertensive, antispasmodic, cardiotonic, anticoagulants and antiplatelet agents, antioxidants, improve metabolism in the 9. Treatment and nervous tissue, rehabilitation of patients who solutions that improve the microcirculation. had stroke. To study the principles of treatment of patients in the restorative and residual periods of stroke.

4.3. Practical tasks to be performed in class: 1. Clinical examination of the patient (physical and neurological). 2. Evaluation of the data from paraclinical study techniques (ECG, REG, TCDG, EEG, Echo-EG, ophthalmoscopy, coagulogram, clinical and biochemical analyzes of blood and urine). 3. Assigning of treatment and writing out prescriptions to patients with vascular diseases of the brain.

Content of the topic:

The blood supply to the brain The blood supply of the brain is provided by two arterial systems: the internal carotid arteries and vertebral arteries. The internal carotid artery is a branch of the common carotid artery, which passes directly from the aorta to the left and from the right subclavian artery to the right. The internal carotid artery enters the cranial cavity through the channel of the same name. Vertebral arteries (VA) originate from the subclavian arteries, enter the channel of the transverse processes of the cervical vertebrae at the level of I cervical vertebra, leave the channel and penetrate through the foramen magnum into the cranial cavity. On the border of the medulla oblongata and the pons, VAs merge into a common stem of large basilar artery. At the front edge of the pons, basilar artery is divided into two posterior cerebral arteries. Communication of two arterial systems (internal carotid and vertebral arteries) is carried out due to the arterial circle of the brain (circle of Willis). The two anterior cerebral arteries anastomose via the anterior communicating artery. Two of the middle cerebral arteries anastomose with the posterior cerebral artery by the posterior communicating artery (each of which is a branch of the middle cerebral artery). Thus, the cerebral arterial circle is formed by the following arteries: • posterior cerebral artery (system of vertebral arteries); • posterior communicating artery (system of internal carotid artery); • middle cerebral (system of internal carotid artery); • anterior cerebral (system of internal carotid artery); • front communicating artery (system of internal carotid artery). The function of the circle of Willis is to maintain the adequate blood flow to the brain: in the disorder of the blood flow in one of the arteries, it is compensated through the anastomosis system. Anterior cerebral artery provides the blood supply to: • cerebral cortex and subcortical white matter of the medial surface in the frontal and parietal lobes of the bottom (basal) surface of the frontal lobe; • upper divisions of precentral and postcentral gyri; • olfactory tract; • 4/5 of the front of the corpus callosum; • head and the outer part of the caudate nucleus; • anterior departments of the lenticular nucleus; • anterior limb of internal capsule Middle cerebral artery provides the blood supply to: • cerebral cortex and subcortical white matter of most of the outer surface of the cerebral hemispheres; • genu and the front 2/3 of the rear limb of the internal capsule; • parts of the caudate and lenticular nuclei; • optic radiation; • Wernicke's center of the temporal lobe; • parietal lobe; • middle and lower frontal gyrus; • low-back department of the frontal lobe; • central lobule. Posterior cerebral artery provides the blood supply to: • cerebral cortex and subcortical white matter of the occipital lobe, the posterior section of the parietal lobe, bottom and rear parts of the temporal lobe; • posterior regions of the thalamus; • hypothalamus; • corpus callosum; • caudate nucleus; • part of the optic radiation; • subthalamic nucleus (the Lewis body); • quadrigeminal plate; • cerebral peduncles. The blood supply of the brain stem and cerebellum is provided by the vertebral artery, basilar and posterior cerebral artery. Basilar artery is involved in the vascularization of the cerebellum and the pons. Blood supply of the cerebellum is performed by three pairs of cerebellar arteries, two of which depart from the main artery (upper and lower front), and one (the lower back) is the largest branch of the vertebral artery. Vertebral arteries form the basilar artery, give two branches merging in anterior spinal artery, and two posterior spinal arteries, not merging and running separately on each side of the rear cords of the spinal cord, as well as two posterior inferior cerebellar arteries. Vertebral arteries provide blood supply to: • medulla oblongata; • posterior lower divisions of the cerebellum; • upper segments of the spinal cord. Among the main risk factors for the formation of chronic circulatory disorders, there are age, physical inactivity, alcohol abuse, smoking, high cholesterol, hypertension, obesity, diabetes, heart disease, mental trauma, genetic predisposition to vascular brain diseases. As pathogenetic bases of cerebral vascular diseases, the change of tone and structure of brain vessel walls, their increasing permeability, the change in rheology, lipid profile, hormonal profile are traditionally considered. The initial manifestations of cerebral circulation disorders. Characteristic features: neurosis, asthenic, hypochondriac syndromes. As an additional method of examination, rheoencephalography method is used. In the analysis of the obtained data, syndrome of regional vascular hypertension, decrease in minute volume of blood circulation, decrease in pulse volume, increase recovery time anacrotism, difficulty of venous outflow from the cranial cavity, the asymmetry of blood flow, reduced elasticity of the vascular wall, reduced vascular reaction in response to the application of vasoactive drugs are observed. On electroencephalogram: general disorganization of biopotentials, no dominant rhythm, hemispheric asymmetry, loss of zonal differences, the appearance of slow waves, deterioration of fast and slow rhythms, reduced depression of α-rhythm in response to light stimulation. According to Doppler ultrasound of the main arteries of the head, the lesion of carotid and vertebral arteries, slowing in the linear flow rate of the common carotid artery, and significant predominance of blood flow in the vessels of vertebrobasilar basin are observed. In the study of blood coagulation properties in these patients, the increased clotting, enhanced hematocrit, increased platelet aggregation and red blood cells are revealed. In the fundus, signs of angiopathy are observed in more than 90% of patients. Dyscirculatory encephalopathy (DEP) implies the chronic progressive form of cerebrovascular pathology, characterized by development of multifocal or diffuse ischemic brain lesions and manifested by complex of neurological and neuropsychological disorders. Unlike ischemic stroke, which is a form of acute cerebrovascular disease, which usually occurs in the focal brain damage, DEP is characterized by a gradual development and multifocal (diffuse) brain damage. DEP in characterized by the tendency to progression, which is usually associated with the accumulation of polymorphic ischemic and secondary degenerative changes in the brain. The main reasons that cause the emergence and development of DEP are arterial hypertension and atherosclerosis. Depending on the etiology, one can distinguish hypertension and atherosclerotic encephalopathies. In view of the clinical manifestations, there are three stages of DEP. The first stage is characterized by diffuse, easily symptomatic brain lesions: the asymmetry of the nasolabial folds, the deviation of speech, anisoreflexia. There are complaints of headache, dizziness, head noises, memory loss (non-professional) and work efficiency. One can differentiate this stage of DEP from initial presentation of cerebrovascular insufficiency by the presence of certain symptoms of organic brain damage and durability of subjective disorders that do not subside after the rest. Asthenic conditions in neuroses, as opposed to DEP, are characterized by a greater lability and dependence on psychogenic effects. At the second stage of the disease, one can observe progressive memory impairment, including the professional one. The range of interests is narrowed, stiff thinking, quarrelsome disposition appear, intelligence is impaired, patient’s personality changes. Daytime sleepiness at bad nocturnal sleep is typical. Compared with the first DEP stage, organic neurological symptoms are enhanced, their number increases. There are mild dysarthria, pathological reflexes, amyotactic symptoms: bradykinesia, increased muscle tone. While at the first stage of DEP work efficiency is essentially retained, at the second one it is significantly reduced. At the third stage of the disease, sharp diffuse changes of brain tissue cause not only the increase in the number and severity of symptoms of organic brain lesions and exacerbation of mental disorders (up to dementia), but also the development of neurological syndromes: pseudobulbar, extrapyramidal, cerebellar. An important place in the clinical picture DEP belongs to emotional and personality disorders. Transient cerebrovascular accident is the acute disorder of brain function of vascular origin, manifested by focal, cerebral or mixed symptoms. The most important criterion of transient cerebrovascular accident is the complete reversibility of focal or diffuse neurological symptoms within 24 hours. Transient cerebrovascular accidents include transient ischemic attacks and cerebral hypertensive crises. Hypertensive cerebral crisis is defined as a condition associated with an acute, usually significant, increase in blood pressure and is accompanied by predominantly neurological symptoms secondary to hypertension. The most severe form of hypertensive crisis is acute hypertensive encephalopathy, which is the basis of the pathogenesis of brain edema. Transient ischemic attacks are characterized by prevalence of cerebral focal symptoms. Graph of logical structure on the topic: acute cerebrovascular accident

Acute cerebrovascular accidents

I. Classification Transient Haemorrhagic Ischemic cerebrovascular accidents strokes strokes

II. Clinical forms Hypertonic Transitory Parenchymatous Intrathecal Intra- Cardio- Athero- Lacunar Hemo- Hemo- embolic thrombotic dynamic reologic crisis ischemic attack hemorrhage hemorrhage ventricular hemorrhage

III. Clinical Sudden Sudden Acute onset manifestations onset onset Impairment of consciousness Premonitory symptoms - General Transient General cerebral symptoms Gradual onset cerebral focal Compression-brainstem symptoms “Fluttering” symptoms symptoms symptoms Impairment of vital functions Consciousness is preserved Transient Autonomic disorders (cyanosis, hyperhidrosis, hyperthermia) Slow development of focal symptoms impairment of Meningeal symptoms Autonomic disorders are less evident consciousness Hemiplegia Hypercoagulation of the blood Hormetonic syndrome in the intraventricular hemorrhage Cerebrospinal fluid is normal Leukocytosis with the shift of blood count to the left Sclerosis of the vessels of the fundus Changes in coagulogram (signs of DIC) EEG: focus of pathological activity The fundus of the eye: hyperemia, swollen disk, hemorrhages REG: decreased blood filling EEG: sharp diffuse violation disorders of electrical activity in the affected vessel Echo-EG: shift of М-Echo ECG: CHD, coronary insufficiency, REG: signs of stasis and edema infarction, atrial fibrillation Angiography: aneurism or arterivenous Angiography: thrombus in the vessel, malformation, cerebrospinal fluid is sanguinolent or angiostenosis xanthochromic Materials for self-check А. Tests for self-check.

Tests to the topic “Vascular diseases of the brain (the initial manifestations of cerebrovascular insufficiency, transient cerebrovascular accidents, chronic cerebrovascular insufficiency)” 1. Identify the arteries of carotid system: a) cerebellar artery b) middle cerebral artery c) subclavian artery d) basilar artery e) vertebral artery

2. Transient ischemic attack is: a) disorder of cerebral functions of vascular origin, having acute onset and subsiding within 24 hours b) disorder of cerebral functions of vascular origin, having acute onset and subsiding within the first 2 hours c) disorder of cerebral functions of vascular origin, having acute onset and subsiding within the first 36 hours d) disorder of cerebral functions of vascular origin, having acute onset and subsiding within the first 72 hours e) disorder of cerebral functions of toxic origin, having acute onset and subsiding within the first 6 hours

3. Transient cerebrovascular disorders include: a) cerebral hypertensive crises b) ischemic stroke c) hemorrhagic stroke d) encephalopathy e) initial manifestations of cerebral circulation insufficiency

4. In the clinical presentation of hypertensive cerebral crisis, the following prevails: a) focal syndromes b) meningeal symptoms c) cerebral symptoms d) damage of cerebral nerves e) epileptiform syndrome

5. The anterior cerebral artery supplies: a) the occipital lobe b) the temporal lobe c) the frontal lobe d) the internal capsule e) the parietal lobe

6. In the localization of stroke in the basin of medial cerebral artery, the following occurs: a) vestibular disorders b) hemiparesis c) alternating hemiplegia d) hearing disorders e) damage of cerebral nerves

7. Identify the basic etiological factors of ischemic stroke: a) hypertension b) cerebral arteriosclerosis c) brain injuries d) brain aneurysm e) arteriovenous malformations

8. Chronic cerebrovascular accidents include: a) encephalopathy b) ischemic stroke c) transient cerebrovascular accidents d) cerebral hypertensive crisis e) hemorrhagic stroke

9. What are the symptoms typical for hemorrhagic stroke? a) retained consciousness b) loss of consciousness c) reduced BP d) atrial fibrillation e) pale skin color

10. Which symptoms are not typical for ischemic stroke? a) transient cerebrovascular accidents in the history b) heart rhythm disorder c) meningeal symptoms d) locomotory impairment e) sensitivity disorder

11. In the clinical presentation of hemorrhagic stroke, the following prevails: a) focal symptoms b) cerebral symptoms c) epileptiform syndrome d) radicular disorders e) vestibular disorders

12. Identify the etiological factors of subarachnoid hemorrhage: a) cerebral arteriosclerosis b) diabetes c) disorder of the rhythm d) aneurysm of cerebral vessels e) rheumatism

13. In the localization of ischemic stroke in the vertebrobasilar basin, the following is typical: a) disorder of the function of cerebral nerves b) central hemiparesis c) aphasic disorders d) apraxia e) agnosia

14. Identify the types of hypertensic cerebral crises: a) akinetic b) regional c) eukinetic d) hypotonic e) mixed

15. Name the syndrome of dyscirculatory encephalopathy of III degree: a) cerebral b) meningeal c) Parkinson's syndrome d) epileptiform e) hyperkinetic

B. Tasks for self-check:

Task 1. A patient, aged 47, during the speech at the production meeting suddenly felt pain in the neck and occipital region, dizziness, "seeing net", feeling hot, sweating developed. The patient was delivered to the admission department. On examination: face and neck are hyperemic, fresh bleeding under the sclera of the right eye. Pulse is tense, 86 / minute; BP − 210 / 120mm Hg. Cardiac sounds are sonorous, accent of II tone on the aorta. The patient is excited, irritable. There is a slight tremor. Meningeal symptoms are not observed. During the examination − vomiting. This condition has developed for the first time. A year ago, at the dispensary examination, increased blood pressure was revealed. Afterwards, the patient did not appeal to the doctor, did not take medications. Make the diagnosis, prescribe treatment and regimen. Is it necessary to hospitalize the patient? What kind of supporting studies should be conducted?

Task 2. A patient, aged 58, works as a health inspector. He complains of unsteadiness when walking, numbness of the right half of the body, hoarseness and complete inability to swallow. The patient has fallen ill 2 months ago: there were headaches, dizziness; once there was vomiting; occasionally he chokes on swallowing. For 2 months, the patient has been taking food through the enteral feeding tube. Objectively: weakened heart sounds, rhythmic pulse, 82 / min, BP 160/90 mmHg. Horner's syndrome to the left, hypoesthesia of the left half of the face, the soft palate slightly hangs down, there is snuffling voice, pharyngeal reflex is absent, swallowing is impossible. One can observe right-sided hemihypesthesia, tendon and periosteal reflexes on the right above, right abdominal reflexes are not induced. On both sides − Marinesco- Radovici sign. There is a slightly ataxic gait, the patient misses the aim when conducting the coordination tests to the left. Make the topical and clinical diagnoses, prescribe treatment, regimen, paraclinical examination.

Task 3. A patient, aged 65, for many years has been monitored by therapist in regard to coronary heart disease and coronarosclerosis. In the evening after washing clothes, the patient developed palpitations, fatigue, cold hands and feet. After some time, the patient developed weakness in the right arm, tingling in the right half of the face and tongue, difficulty in speech. The patient was taken to the hospital. On examination: the patient is pale, the skin is moist and cold. Lips are cyanotic. Pulse is of weak filling, arrhythmic 110 / min, BP 85/50 mm Hg. Consciousness is clear. Meningeal symptoms are not observed. Right nasolabial fold is slightly smoothed, there is the tongue diversion to the right. Motor aphasia, deep paresis of the right hand, decreased muscle tone. The tendon reflexes in the right arm and leg are increased. REG: on hemispheric REG the shape of apex is arcuate, there is a sharp decline in REG amplitude in the section of the left front-mastoidal abduction. Make the topical and clinical diagnoses, prescribe the treatment mode. What other laboratory tests should be done?

Task 4. A patient, aged 33, works as a loader in the restaurant. He was delivered by emergency ambulance to the hospital in a severe condition. According to the accompanying people, it has been revealed that earlier he had not been ill; the patient drinks alcohol to excess. On the day of admission, after great physical and emotional stress, he complained of acute headache, and was excited. The patient drank half a glass of brandy, his condition deteriorated: there are repeated vomiting, increased headache and excitement. Objectively: the face is hyperemic, the skin is moist. Rhythmic pulse, 110 per minute, blood pressure − 120/80 mm Hg. Rhythmic breathing. The body temperature is 37.5˚C. Consciousness is confused, the patient cannot tell about himself, he is disoriented in time and place. The patient fails to come in contact with surrounding people, he is excited, talks much and loudly, constantly tries to get up, groans. There are severe neck stiffness, positive Kernig’s and Brudzinski’s symptoms; slightly limited abduction of the eyeballs. No pareses. Sensory loss is not detected. The tendon reflexes are equally lively, with bilateral Babinski’s symptom, grasping reflex. Make the topical and clinical diagnoses, prescribe treatment, regimen, paraclinical examination.

Task 5. A patient, aged 44, is a teacher by profession. He has been suffering from hypertensive disease for several years; in the last 2 years experienced cerebral crises for many times with increased pressure up to 240 / 120 mm Hg. The patient has been on the sick leave for 10 days in regard to hypertensive crisis, headaches, malaise. In the evening, after taking a bath, his condition rapidly deteriorated: headache increased, vomiting appeared, the patient ceased to recognize other people, did not understand their speech, then lost consciousness. On examination: the patient's condition is severe, pastous face of bluish-red color. Breathing is noisy, accelerated up to 50 per minute. Pulse is tense, rhythmic, 96 / min. BP 260 / 140 mm Hg, moist skin. Body temperature − 37.8˚C. Consciousness is lost, the patient does not respond to pain stimuli. There are stiff neck, Kernig’s and upper Brudzinski’s symptoms to the left. The head and eyes are diverted to the left. The right cheek is sailing. No movement in the right hand, it is passively raised and falls; the left arm is slowly lowered. The symptom of rotated foot to the right, increased tendon reflexes to the right, Babinski’s, Oppenheim’s, Rossolimo’s symptoms to the right. Make the topical and clinical diagnoses, prescribe treatment. It is necessary to manage the patient’s admission, to prescribe the necessary paraclinical methods. Provide the prognosis for this patient.

Task 6. A patient, aged 48, is a doctor by profession. He has been suffering from hypertensive disease for several years, and was periodically treated. Yesterday, after emotional stress, the patient developed nausea and acute headache, as if "something hit him". Painkillers and vasodilators did not help, he did not sleep all night; next morning the patient was admitted to the hospital. Objectively: normal temperature. Certain excitement is observed, the patient’s face is slightly hyperemic. Pulse is tense, 56 / minute. BP − 220 / 130mm Hg. Meningeal symptoms are sharply pronounced: stiff neck, Kernig’s symptom, photophobia, general hypersensitivity. Cranial nerves are without pathology. No pareses. Reflexes are lively, uniform. Make the diagnosis, prescribe treatment, regimen, examination.

Task 7. A patient, aged 53, complains of repeated vomiting, dizziness, which intensified when changing the head position. The onset was acute: during the conversation with colleagues, she suddenly felt dizzy, "everything swam before her eyes," there was nausea and then vomiting. This happened for the first time. In the last few years, the deterioration of memory has been noticed. Objectively: the patient lies on the right side with eyes closed, when trying to change the position, she starts vomiting. Consciousness is clear. Horizontal nystagmus when looking to the right. Noise in the right ear. Phonation and swallowing are not impaired. Pharyngeal reflex is lively. No weakness in the limbs. The tendon reflexes are lively, steady. No pathological reflexes. BP − 150 / 80 mmHg. Heart sounds are muffled. Reduced pulsation of arteries in the back of soles. On the fundus: constricted retinal arteries. All these symptoms resolved within 10 hours. Make the topical and clinical diagnoses, prescribe treatment, examination.

Task 8. A patient, aged 57, was admitted in the department with complaints of weakness and clumsiness in the right hand and foot, slight difficulty with speech. The patient fell ill 2 years ago, when he suddenly felt numbness in the right hand. He came home and felt numbness in the right leg. In the morning after sleep, movement in the right arm and leg disappeared, it became difficult for him to talk. He was delivered to the hospital. After 2 weeks, the condition improved, the movement began to recover. Objectively: BP 150/90 mmHg. Heart sounds are slightly weakened. There is weakness of the facial muscles to the right in the lower part of the face, the tongue when protruded is deflecting to the right. Muscle strength in the right extremities is reduced up to 3 points, increased muscle tone by the spastic type. Tendon reflexes are increased to the right, clonus of the right foot, Babinski’s and Rossolimo’s symptoms to the right. On both sides − Marinesco-Radovici sign. Slight hemihypesthesia to the right. Hemiparetic gait, Wernicke-Mann posture. On the fundus: constricted retinal vessels. REG: the shape of top of the wave is rounded, the notch and catacrotic wave are smoothed, the inclination angle of ascending part is increased, the time of ascending part is increased, the amplitude of the REG-wave is reduced. Blood tests: fibrinogen − 4.11 g / l, prothrombin index − 120%. Make the clinical, functional and topical diagnosis, determine the ability to work, prescribe treatment, provide guidance as to the patient’s regimen.

Task 9. A patient, aged 54, called in a doctor; he complains of weakness and limitation of movement in the left hand, tearfulness, difficulty with speech and swallowing. The patient fell ill a year ago, when he woke up at night, tried to get up and felt that the left hand did not move. Doctor of emergency ambulance said that the patient had high blood pressure and prescribed him treatment. Three days later, the movements in hands were gradually restored, the patient noticed some difficulty in speech and swallowing. It is known that the increased pressure has been observed in the patient for over 5 years. Objectively: heart sounds are rhythmic, pulse is strained, 74 / min. BP is 220/105 mmHg. There is weakness of the facial muscles in the lower part of the face to the left, the tongue is deflected to the left; slight dysarthria, the patient sometimes chokes on swallowing, pharyngeal reflex is preserved. Pronounced lip reflex and Marinesco-Radovici sign. Range of motion in the left hand is limited, the strength is reduced, tone is increased. Reflexes of hand are above to the left. Movement of the legs is in the full extent, of normal strength; reflexes are steady. Babinski’s symptom to the left. ECG: ischemia of the posterior wall of left ventricular. Make the diagnosis, prescribe treatment, regimen, additional studies.

Task 10. A patient was taken from the street unconscious. He is about 60 years old. The face is pale, pupils of normal width, reaction of pupils is absent. The right cheek sails when breathing. The right limbs fall down; in the left ones − stereotyped movements are periodically observed. Muscle tone in the right extremities is reduced, the symptom of the rotated foot. Reflexes to the right are increased, clonus of the right foot. Bilateral Babinski’s, Oppenheim’s symptoms. No meningeal symptoms. Weakened heart sounds, atrial fibrillation. BP 150/100 mmHg Studies were conducted in the emergency department. Fundus of the eye: retinal blood vessels are constricted. Liquor: normal pressure, colorless, transparent, protein − 0.66 g / l, cytosis − 3 lymphocytes in 1 mcl, glucose − 3.2 mmol / l. Blood tests: without clinical pathology. REG: the shape of apex is arch-like, there is a sharp decline of the REG amplitude in the section of the left front-mastoidal abduction. Echo-EG: shift of M-echo is not revealed. Make the topical and clinical diagnoses, prescribe treatment.

Task 11. A patient, aged 57, presented with periodically increased blood pressure and headaches within the last 6 years. Six months ago, in the morning the patient felt weakness in the right hand, later in the day, the right leg began to grow feeble, until the evening movement completely disappeared, and there was difficulty with speech. The patient underwent treatment at home, two weeks later the speech was restored, movements in the leg, then in the hand came back. In a month, the patient began to walk, but there was a persistent intense pain in the whole right half of the body, which is reduced only at night. Analgesics do not relieve the pain. Objectively: BP-150/90 mm Hg. Rhythmic pulse, cardiac activity is normal. In the neurological status: right-sided hemianopsia, weakness of facial muscles on the right by the central type. Right-sided hemiparesis, muscle tone is increased by spastic type. Wernicke-Mann position. Reflexes to the right are increased, positive Babinski’s sign. On the right: slight hemihypesthesia with the manifestations of hyperpathia, in the fingers of the right leg muscle-joint feeling is reduced. Hemiparetic gait. On the fundus: constricted retinal vessels. REG: the shape of the top of the waves is rounded, the notch and catacrotic wave are smoothed, amplitude of REG-wave is reduced. Blood tests: fibrinogen − 3.11 g / l, prothrombin index − 100%. Make the clinical, functional and topical diagnosis, prescribe treatment.

Task 12. A patient, aged 56, was delivered at the department in a severe unconscious condition. According to the relatives, it has been found out that she suffered from hypertension for a long time, and was under the cardiologist’s follow- up. In the right extremities − periodic parakinesis (stereotyped movements), the left limbs are immobile, left foot is rotated outwards. There is hypotonia in all limbs, periodic general tonic convulsions (hormetonic syndrome). Reflexes from the limbs are sharply weakened. Babinsiki’s, Oppenheim’s symptoms to the left. There is no reaction to piercing injections. Stiff neck muscles. Temperature − 39˚C, blood pressure − 240/130 mm Hg. Pulse is tense, rhythmic, 120 / min. Cardiac sounds are sonorous, accent of tone II on the aorta. Lumbar puncture: bloody CSF. Make the topical and clinical diagnoses, prescribe treatment.

Task 13. A patient, aged 65, was admitted to the hospital with complaints of double vision, weakness in the right arm and leg. The patient has fallen ill suddenly: double vision developed for no apparent reason, then the left eyelid descended, and a few hours later, weakness in the right arm and leg was felt. Up to this disease, the patient periodically noticed headaches, disturbance of gait, dizziness. He complains of memory loss. Objectively: BP − 160/100 mmHg, pulse is arrhythmic. Cardiac sounds are weakened. Pulsation of vessels in the feet is weakened. In the neurological status: vessels of the fundus are constricted. There is ptosis to the left, mydriasis, sharply weakened pupillary reaction to light, to the convergence and accommodation, exotropia, convergence disorder. Weakness of the facial muscles of the lower face to the right. Muscle strength in the right extremities is reduced up to 3 points, increased tone. Reflexes to the right are increased, abdominal ones are reduced positive Babinski’s, Rossolimo’s, Zhukovsky’s symptoms. REG: the form of REG-wave apes is rounded, the amplitude is reduced, the notch and catacrotic wave are smoothed. Blood tests: prothrombin index is 105%, plasma tolerance to heparin − 1min30s, fibrinolysis − 240 min. Make the topical and clinical diagnoses, prescribe treatment.

Task 14. A patient, aged 58, suffers from essential hypertension for 8 years. 3 years ago, after the troubles at work, he suddenly felt numbness in the right cheek and hand, then lost consciousness. He regained consciousness at the hospital in a couple of hours, there was loss of speech, paralysis of the right extremities. This afternoon he developed acute headache, dizziness, and repeated vomiting. The patient was taken to hospital. Objectively: BP − 230/135 mmHg. Borders of the heart are extended to the left, accent of II tone on the aorta. Pulse is tense, 78 / minute. When grinning, the right angle of the mouth opens worse. Right-sided hemiparesis with reduced strength in the hand up to 2 points, in the leg − up 3. Hemiparetic gait, Wernicke-Mann’s posture. Muscle tone in the right extremities is elevated according to the spastic type. Romberg position is unstable. Pronounced lip reflex, Marinesco-Radovici sign, compulsive weeping. Speech is slightly impeded, some words are incorrectly pronounced, the patient often cannot find the right word. Instructions are performed correctly. On the fundus: vessels are sclerous. ECG: disorder of intraventricular conduction, ischemia in the posterior wall of the left ventricle. Coagulogram of the blood: without pathology. REG: hemispheric asymmetry, the amplitude of the curve to the left is much less than the right one. The sharp rise of anacrotic phase and sharp descent of catacrotic phase of REG-wave. On both sides, venous waves are registered. Make the clinical, functional and topical diagnosis, prescribe treatment.

Task 15. A patient, aged 52, was taken to the hospital by emergency ambulance. She was picked up at the store, where she stood in the queue; it was hot, she suddenly lost consciousness and fell down. Objectively: the pulse is intense, rhythmic, 80 / min. Blood pressure − 200/120 mm Hg. The level of consciousness − coma. The face is purple, swollen, restless breathing, the right cheek sails when breathing. Pupillary reaction is missing. Eyes are turned to the left. Muscle tone in the extremities is reduced, the reflexes are not induced. Right hand falls down, right foot is rotated outward. Positive Babinski’s reflex to the right. Kernig’s symptom is blurred positive. Make the diagnosis, prescribe treatment and the necessary examination.

REFERENCES Basic: 1. Marshall R. On Call Neurology. Philadelphia: Saunders. − 1997. − 96 p. 2. Nath A., Berger J.R., eds. Clinical Neurovirology. − New York: Marcel Dekker, Inc. − 2003. − 370 p. 3. Rowland L.P., Pedley T.A. Merritt's Neurology [12th Edition]. − Lippincott Williams & Wilkins, 2010. − 280 p. 4. Yogarajah M. Crash course Neurology. − Institute of Neurology (University College London). − 2015. − 163 p. Additional: 1. 1. Cohon M.A., Gorman J.M. Comprehensive textbook of AIDS. Psychiatry. − Oxford, 2008. − 619 p. 2. 2. Lindsay K.W., Bone I. Neurology and Neurosurgery Illustrated. − Churchill Livingstone, third edition. − 1997. − 545 p. Web resources: http://www.umsa.edu.ua/ http://st.asvomed.ru/php/content.php?id=3515 http://vmede.org/sait/?id=Nevrologija https://www.youtube.com/watch?v=8SE26hB9y7Y; https://www.youtube.com/watch?v=lBZzmVcheeo; https://www.youtube.com/watch?v=s2vH6y7Ez3I http://www.rmj.ru/articles/nevrologiya/Sovremennye_predstavleniya_o_hronichesko y_nedostatochnosti_mozgovogo_krovoobrascheniya/#ixzz4a0J7O9SP http://meduniver.com/Medical/Neurology/120.html MedUniver http://medbe.ru/materials/cherepno-mozgovye-narusheniya/prekhodyashchie- narusheniya-mozgovogo-krovoobrashcheniya-tranzitornye-ishemicheskie-ataki/

The methodical guidance has been compiled by______V.M. Hladka The methodical guidance has been considered and approved at the meeting of the Department of Nervous Diseases with Neurosurgery and Medical Genetics ______and subsequently revised (amended) ______

Head of the Department of Nervous Diseases with Neurosurgery and Medical Genetics D.Med.Sci., Professor N.V. Lytvynenko