Clinical Institute of Brain

INTRODUCTION: Patients with disorders of consciousness (DoC) represent a complex patient cohort requiring a multidisciplinary approach. Despite the availability of modern national clinical guidelines (2023), real-world clinical practice in Russia continues to be challenged by the use of outdated terminology, insufficient implementation of validated diagnostic scales, and a lack of standardized management approaches, including pain assessment and management. This study was prompted by the need to assess the current situation and identify key issues to improve the quality of care for patients with DoC in Russia. OBJECTIVE: To assess the current practices, awareness, and key challenges faced by Russian healthcare professionals in the diagnosis, treatment, and management of patients with chronic DoC. MATERIALS AND METHODS: In 2024, an anonymous online survey of 204 medical and paramedical professionals (anesthesiologists, neurologists, rehabilitation specialists, psychologists, nursing staff) from various regions of Russia was conducted. The 47-item questionnaire covered demographic data, terminology used, diagnostic scales, treatment and rehabilitation methods, as well as approaches to pain assessment and management. RESULTS: Despite modern clinical guidelines, outdated terminology persists in practice: apallic syndrome (13.3 %), vegetative state. Only 62.9 % of respondents use the validated Coma Recovery Scale-Revised (CRS-R) for DoC diagnosis, while 77.1 % still use non-relevant scales (Glasgow Coma Scale, Full Outline of UnResponsiveness — FOUR). 30 % of respondents, including physicians responsible for diagnosis, use exclusively these non-relevant tools. Significant differences in approaches were identified among specialists of different profiles (intensivists, neurologists, rehabilitation specialists). The majority of respondents (83 %) acknowledge that DoC patients experience pain; however, the assessment methods (autonomic signs, grimacing) are not standardized and can be non-specific. CONCLUSIONS: The study results indicate insufficient awareness and fragmented implementation of modern standards for the diagnosis and management of patients with DoC in Russia. The findings highlight the necessity of developing and implementing educational programs for healthcare professionals aimed at standardizing terminology, promoting the use of validated diagnostic scales (CRS-R), and harmonizing approaches to pain management.

BACKGROUND: It is known that regular physical activity stimulates synaptic plasticity in the central nervous system. Neurons involved in movement and sensory integration form new connections, contributing to the restoration of lost functions (angiogenesis, neurogenesis, changes in cortical pathways). Based on this, it was hypothesized that KRISAF device (locomotor therapy in unweighted conditions) in patients with chronic disorders of consciousness, due to the presence of passive stereotyped motor cycles mimicking crawling/swimming/walking, may modulate the recovery of cerebral hemisphere functions and subsequently affect the level of consciousness through the mechanism of afferent ontogenetic “recollection.” AIM: To assess the changes in cerebral hemisphere function recovery based on the scores of the CRS-R, Behavioral Pain Scale, Ashworth Scale, and Glasgow Outcome Scale Extended (GOS-E) in patients with chronic disorders of consciousness undergoing locomotor therapy in unweighted conditions. MATERIALS AND METHODS: A descriptive prospective comparative cohort study included 74 patients from 2019 to 2024. They were divided into two groups: intervention group (n=44) and control group (n=30). Patients in the intervention group, in addition to the main course of rehabilitation treatment, received 5 sessions of locomotor therapy in unweighted conditions. RESULTS: The median level of consciousness score according to the CRS-R scale in the intervention group increased from 6 (5.4–6.6) to 9 (8.1–9.9) points (p=0.0006), while in the control group, it increased from 5.5 (4.7–6.3) to 7 (6–8) points (p=0.0609), indicating a statistically significant difference (p 0.00001). CONCLUSION: The significant improvement in the CRS-R score at discharge among patients undergoing locomotor therapy indicates that this treatment method has a positive effect on the level of consciousness.

Chronic disorders of consciousness include several conditions that differ significantly in both clinical and neurophysiological features. As medical technology continues to develop, the differential diagnosis of disorders of consciousness extends beyond purely clinical work. Nevertheless, all types of consciousness disorders are united by varying degrees of dissociation between wakefulness, cognitive and motor activity. The external similarity and minimal differences in clinical symptoms in unresponsive patients may hide different morphofunctional variants of this condition. In particular, use of electroencephalography and functional magnetic re- sonance imaging techniques allows us to detect covert consciousness in some clinically unresponsive patients. Based on various estimates, this phenomenon occurs in 515% of all cases. A special instance of covert consciousness is cognitive motor dissociation (CMD), defined as activation of cortical motor centers, recorded using neurophysiological techniques, in response to a corresponding instruction to perform a movement without its visible performance. Some researchers believe that detection of CMD indicates a more favourable prognosis for the subsequent restoration of consciousness, rather than its absence. The aim of this review is to examine CMD and its potential significance for outcomes in patients with chronic disorders of consciousness.

Relevance . For the acute phase of cerebral insufficiency (ACI) analysis of energy demand at rest (REE) using indirect calorimetry method is effective to evaluate the level of hypermetabolism and selection of optimal nutritional support. In patients with chronic impairment of consciousness (CIC) the reasonability of such an approach is shown, but in this category of patients the influence of rehabilitation measures on energy demand is not taken into account. Verticalization is a routine method of prevention and treatment of immobilization syndrome in patients with ACI and its consequences today. Aim of study . To determine the effect of the verticalization procedure on the turntable on the dynamics of REE index in patients with unresponsive wakefulness syndrome (UWS). Material and methods . A prospective, comparative, non-randomized study was conducted in 136 patients in the neuro-intensive care unit of the Brain Institute Clinic. The REE index was determined using the method of indirect calorimetry without load and during verticalization in 75 patients with UWS and in 51 patients of the intensive care unit, who also underwent ACI, but were clearly conscious. Results . In patients with clear consciousness during verticalization REE increased by an average of 300 kcal (20%) from the initial values. The energy value of verticalization was about 5 kcal/kg. On the contrary, in the group of patients with UWS, the verticalization procedure practically did not increase the energy consumption, and the energy value of verticalization slightly exceeded 1 kcal/kg. Conclusion . Patients with UWS have a special metabolic status, probably due to a decrease in the functional activity of the brain. This can be confirmed using indirect calorimetry.

The emergence of SARS-CoV-2 and its worldwide spread has become a challenge for healthcare professionals related to rapid diagnosis of infection caused by the new coronaviruses, provision of specialized medical care, rehabilitation and secondary prevention. Currently, there is limited information on primary, secondary prevention and medical rehabilitation of this disease. The most common clinical manifestation of the new variant of coronavirus infection is bilateral pneumonia, with 34% of patients developing acute respiratory distress syndrome (ARDS). Given the unusual pandemic situation and the peculiar COVID-19 pathogenesis, the stereotyped application of generally accepted methods may be unsafe or ineffective. The Union of Rehabilitologists of Russia has prepared Temporary guidelines that are based on the advice on medical rehabilitation of patients with COVID-19 at various stages of special medical care published by WHO specialists, analysis of reports from clinics currently involved in rehabilitation of COVID-19 patients, as well as on the results of clinical studies conducted earlier on the rehabilitation of patients with Post-intensive care syndrome and adult respiratory distress syndrome (ARDS) of non-coronavirus etiology, regulatory documents of the Russian Ministry of Health and Federal Service on Surveillance for Consumer rights protection and human well-being. A syndrome-based approach to the use of means and methods of physical and rehabilitation medicine is also considered. The guidelines are intended for heads of medical organizations and their structural divisions, general practitioners, physicians, infectious disease doctors, pediatricians, emergency physicians of intensive care units in infectious hospitals, physiotherapy and sports medicine doctors, physiotherapists, medical psychologists, physical therapy instructors, nurses and other specialists of multidisciplinary rehabilitation teams working in the field of medical care for patients with COVID-19 at various stages.

About 20% of all road traffic accidents may be associated with falling asleep while driving. This may be caused by sleep disorders leading to daytime sleepiness, the most common of which is obstructive sleep apnea syndrome (OSAS). Objective : to study somatic and mental health, sleep disorders, OSAS in particular, in the population of Russian drivers (Sverdlovsk Region). Patients and methods. The descriptive cohort «Dangerous Sleep» (DS-1) study of 20 professional drivers having more than 5-year driving experience was conducted at the Clinical Institute of the Brain. The mean age of the drivers was 45.8 years. They underwent somatic evaluation for cardiovascular risk factors and a psychological examination involving a risk readiness diagnostic procedure, the Zung Self-Rating Depression Scale, the Beck Depression Inventory, and an electroencephalographic examination. A somnological examination assumed testing using the Epworth sleepiness scale, polysomnography, or overnight pulse metry. Results and discussion. 30% of the drivers were found to have marked attention disorders and an inability to adapt to extreme conditions, which create a risk for professional duties. The predisposing factors were noted to be alcohol addiction, overweight, and OSAS, the rate of the latter proved to be higher than that in the general population of able-bodied men. It was shown that a somnological examination should be obligatorily performed while hiring professional drivers, particularly to long hauliers. The drivers having a long length of experience, in whom a periodic examination detects sleep disorders, should be treated for somatic diseases and should also have individual working schedules to rule out their long night-time driving.

Granulocyte-colony-stimulating factor (G-CSF) functions both as a neuroprotectant and a stimulator of autologous bone marrow stem cell release. Therefore, administration of G-CSF should improve the outcome of stroke. Here, we examine the safety of using G-CSF to treat acute ischemic stroke using a randomized controlled trial involving 20 adult patients presenting with ischemia in the carotid region within 48h of onset. The experimental group (n = 10) received subcutaneous G-CSF injections (10mgkg(-1)day(-1)) in addition to conventional therapy for 5days. The primary outcome was motor function as measured by the modified Rankin Scale 180days post-stroke. Safety was evaluated according to the frequency of hemorrhagic transformation of infarctions and serious adverse events. Only six patients in the experimental group completed full course of treatment, while four patients (three in the control and one in the experimental group) were lost to follow-up. We found the experimental and control groups did not differ significantly in either neurological impairment or degree of disability/dependence at 180days post-stroke. We conclude that while adding G-CSF (10mgkg(-1)day(-1)) to acute ischemic stroke therapy for 5days is safe, its efficacy remains unproven.