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ISSN 1311-8641

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology ë‰ÛÊÂÌË ◊Å˙΄‡ÒÍÓ ‰ÛÊÂÒÚ‚Ó ÔÓ Ì‚ÓÎÓ„Ëfl“ Official Journal of The Bulgarian Society of Neurology íéå 7 / Åêéâ 2 Äèêàã, 2007

VOLUME 7 / NUMBER 2 APRIL, 2007

ëöÑöêÜÄçàÖ

CONTENTS

éÅáéêà

REVIEWS

ïàêìêÉàü çÄ ÖèàãÖèëàüíÄ – àçÑàäÄñàà à ÇöáåéÜçéëíà (I) èÂÚfl ÑËÏÓ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

EPILEPTIC SURGERY – INDICATIONS AND POSSIBILITIES (I) Petia Dimova . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

ïàêìêÉàü çÄ ÖèàãÖèëàüíÄ - èêÖïàêìêÉàóçÄ ÑàÄÉçéëíàäÄ (II) èÂÚfl ÑËÏÓ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

EPILEPSY SURGERY - PRESURGICAL EVALUATION (II) Petia Dimova . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

îÄêåÄäéàäéçéåàäÄ à ÖèàãÖèëàü è. Ň··‡ÌÓ‚, á. á‡ı‡Ë‚ . . . . . . . . . . . . . . . . . . . . . . . .63

PHARMACOECONOMICS AND EPILEPSY P.Balabanov, Z.Zahariev . . . . . . . . . . . . . . . . . . . . . . . . . .63

çÖÇêéçéèêéíÖäñàü ëöë CITICOLINE èêà àëïÖåàóçà åéáöóçà àçëìãíà à óÖêÖèçéåéáöóçà íêÄÇåà è. ëÚ‡ÏÂÌÓ‚‡, å. åË·ÌÓ‚‡, Ñ. Äڇ̇ÒÓ‚‡, å. ꇉ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

NEUROPROTECTION WITH CITICOLINE IN PATIENTS WITH ISCHEMIC STROKES AND BRAIN INJURIES P. Stamenova, M. Milanova, D. Atanasova, M. Radeva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

ëäêàçàçÉéÇà çÖÇêéèëàïéãéÉàóçà íÖëíéÇÖ áÄ äéÉçàíàÇçà çÄêìòÖçàü à ÑÖåÖçñàü à. ÑËÏËÚÓ‚, ç. ÑÂ΂‡,ã. í‡ÈÍÓ‚ . . . . . . . . . . . . . . . .74

NEUROPSYCHOLOGICAL SCREENING TESTS FOR COGNITIVE IMPAIRMENT AND DEMENTIA I. Dimitrov, N. Deleva, L. Traykov . . . . . . . . . . . . . . . . . . .74

éêàÉàçÄãçà ëíÄíàà

ORIGINAL PAPERS

ãÖäà äéÉçàíàÇçà çÄêìòÖçàü èêà èÄñàÖçíà ë èÄêäàçëéçéÇÄ ÅéãÖëí å. èÂÚÓ‚‡, å. ê‡È˜Â‚‡, ü. ÜÂ΂ , ã. í‡ÈÍÓ‚ . . . . . . .77

MILD COGNITIVE IMPAIRMENT IN PATIENTS WITH PARKINSON’S DESEASE M. Petrova, M. Raycheva, Y. Zhelev, L. Traykov . . . . . . . . .77

åàçàåÄãçÄ óÖêçéÑêéÅçÄ ÖçñÖîÄãéèÄíàü èêà èÄñàÖçíà ë óÖêçéÑêéÅçÄ ñàêéáÄ è. Äڇ̇ÒÓ‚‡, ç. ä¸ÒÚ‚, ê. å‡Ò‡Î‰ÊË‚‡, ä. Ňı˜Â‚‡ÌÓ‚, Ä. åËı‡ÈÎÓ‚‡, É. åÛÁË͇‰ÊË‚‡, ï. è‡ÛÌÓ‚‡, å. äÓÒÚ‡‰ËÌÓ‚‡, Ñ. ÉÂÓ„Ë‚ . . . . . . . . . . . .80

MINIMAL HEPATIC ENCEPHALOPATHY IN PATIENTS WITH LIVER CIRRHOSIS

ìãíêÄáÇìäéÇé ÑìèãÖäë-ëäÖçàêÄçÖ çÄ ëöççàíÖ ÄêíÖêàà èêà Åéãçà ëöë áÄïÄêÖç ÑàÄÅÖí à ÑàÄÅÖíçÄ èéãàçÖÇêéèÄíàü è. чÏflÌÓ‚, ç. ÑËÏ.ÑËÏËÚÓ‚, ç. ÑÓÍ.ÑËÏËÚÓ‚, ã. á‡ÔflÌÓ‚‡, Ç. ÑËÏËÚÓ‚‡, Ñ. ÅÓ„‰‡ÌÓ‚‡, à. ÇÂΘ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

ULTRASAOUND DUPLEX-SCANNING OF THE CAROTID ARTERIES IN PATIENTS WITH DIABETES MELLITUS AND DIABETIC NEUROPATHIY P. Damianov, N. Dim.Dimitrov, N. Doc. Dimitrov, L. Zaprianova, V. Dimitrova, D. Bogdanova, I.Velcheva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

P. Atanassova, N. Krustev, R. Massaldjieva, K. Bahchevanov, A. Michajlova, G. Muzikadjieva, H. Paunova, M. Kostadinova, D. Georgiev . . . . . . . . . . . . .80


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

Publisher Color Studio®

ë‰ÛÊÂÌË ◊Å˙΄‡ÒÍÓ ‰ÛÊÂÒÚ‚Ó ÔÓ Ì‚ÓÎÓ„Ëfl“ Official Journal of The Bulgarian Society of Neurology êÖÑÄäñàéççÄ äéãÖÉàü

EDITORS

ÄÎÂÍÒË‚ Ä. ŇΉ‡‡ÌÓ‚ Ñ. ÅÓÊËÌÓ‚ ëÚ. ÅÓÊËÌÓ‚‡ Ç Ç‡ÒË΂‡ Ö. LJÒË΂‡ í. ɇÌ‚‡ É. ÉÂÓ„Ë‚ Ñ. ÉÂ‡ÒËÏÓ‚ Å. ÉÓÁχÌÓ‚ É. ÉË„ÓÓ‚‡ é. ÑÂ΂‡ ç. á‡ı‡Ë‚ á. à‚‡ÌÓ‚‡ ã. à¯ÔÂÍÓ‚‡ Å. äÓ΂ é. å‡Ì˜Â‚ à. å‡Ò·Ó‚ Ñ. åË·ÌÓ‚ à. åË·ÌÓ‚‡ å. åË̘‚ Ñ. çËÍÓ‚ÒÍË ç. èÂÚÓ‚ à. èÂÚÓ‚‡ û. ê‡È˜Â‚ à. ꇯ‚‡ å. ëÚ‡ÏÂÌÓ‚ Å. íËÚflÌÓ‚‡ Ö. í‡ÈÍÓ‚ ã. í˙Ì‚ à. ÂÁÓ‚‡ ã. ÊË‚ Ñ ï‡‰ÊËÔÂÚÓ‚‡ Ö. ï‡‡Î‡ÌÓ‚ ã. ñ‡ÌÍÓ‚‡ ñ. ó‡Î˙ÍÓ‚‡ ç. óÂÌËÌÍÓ‚‡ ë. òÓÚÂÍÓ‚ è. ü̘‚‡ ë.

Alexiev A. Baldaranov D. Bojinov St. Bojinoba V. Vassileva E. Vassileva T. Ganeva G. Georgiev D. Gerassimov B. Gozmanov G. Grigorova O. Deleva N. Zahariev Z. Ivanova L. Ishpekova B. Kolev O. Manchev I. Maslarov D. Milanov I. Milanova M. Minchev D. Nikoevsky N. Petrov I. Petrova U. Raychev I. Rasheva M. Stamenov B. Titianova E. Traykov L. Tarnev I. Havezova L. Hadjiev D. Hadjipetrova E. Haralanov L. Tzankova Tz. Chalakova N. Charninkova S. Shotekov P. Yancheva S.

ëÓÙËfl ëÓÙËfl è΂ÂÌ ëÓÙËfl ëÓÙËfl èÎÓ‚‰Ë‚ ëÓÙËfl ëÓÙËfl ëÓÙËfl èÎÓ‚‰Ë‚ ëÓÙËfl LJ̇ èÎÓ‚‰Ë‚ ëÓÙËfl ëÓÙËfl ëÓÙËfl ëÚ.ᇄÓ‡ ëÓÙËfl ëÓÙËfl ëÓÙËfl LJ̇ ëÓÙËfl ëÓÙËfl ëÓÙËfl ëÓÙËfl ëÓÙËfl è΂ÂÌ ëÓÙËfl ëÓÙËfl ëÓÙËfl LJ̇ ëÓÙËfl èÎÓ‚‰Ë‚ ëÓÙËfl ëÓÙËfl èÎÓ‚‰Ë‚ ëÓÙËfl ëÓÙËfl ëÓÙËfl

ÉãÄÇçà êÖÑÄäíéêà: à. åË·ÌÓ‚, è. ëÚ‡ÏÂÌÓ‚‡, à. ÇÂΘ‚‡ ëÖäêÖíÄê: å. чÒ͇ÎÓ‚

Sofia Sofia Pleven Sofia Sofia Plovdiv Sofia Sofia Sofia Plovdiv Sofia Varna Plovdiv Sofia Sofia Sofia St. Zagora Sofia Sofia Sofia Varna Sofia Sofia Sofia Sofia Sofia Pleven Sofia Sofia Sofia Varna Sofia Plovdiv Sofia Sofia Plovdiv Sofia Sofia Sofia

EDITOR IN CHIEF: I. Milanov, P. Stamenova, I. Velcheva SECRETARY: M. Daskalov


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology ìäÄáÄçàÖ áÄ ÄÇíéêàíÖ

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl

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INSTRUCTION FOR AUTHORS

Bulgarian Neurology

is the official journal of the Bulgarian Society of Neurology. It will consider for publication papers in neurology and related areas in the following categories: -Editorials, consisting of up to 3 pages, when approved by the Editorial Board -Original papers - up to 8 pages, including tables, figures and references. An abstract in Bulgarian and English up to 40 rows on a separate sheet is required. The abstract should contain title, authors, objective, background, methods, results and conclusions plus up to 6 keywords. The original papers include short introduction, material, methods results, discussion and references. The title page should carry the full title, the short running title, the authors with their initials, academic degrees, institutional affiliations, address for correspondence, with telephone, fax and e-mail -Short communications and case reports up to 3 pages -Review articles up to 10 pages -Book reviews and information. It includes information for new books, congresses and conferences, new drugs, future events in neurology -Letters to the Editor with comments on previously published papers, short case reports and discussion on current problems -The manuscripts should be submitted on diskette / 3.5 inch/ using Word 6/Windows 96 or Word7/Windows 98 with a printed copy. The tables should be presented on separate sheets with a short heading The illustrations /figures, diagrams, formulas/ should be ready for reproduction. Explanatory legends should be provided on a separate sheet of paper. References should be presented in alphabetic order on a separate sheet with all authors` names and full title of papers . In the text the authors should be indicated by the number from the reference list . The reference should be presented as follows: Journal paper : (1) author(s), (2)title, (3) journal name ( as abbreviated in Index Medicus ). (4) volume, (5) year of publication, (6) journal number , (7) inclusive pages. Example: Andersen, G., Vestergaard, K., Lauritzen, L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke, 25, 1994, 6, 10991104. Book : (1) author(s), (2) title, (3) city of publication, (4) publisher, (5) year of publication , (6) pages. Example : Calligaro,K., DeLaurentis, D., Baker, W. Management of Extracranial Cerebrovascular Disease.Philadelphia-New York, Lippincott - Raven Publishers, 1997, 217. References to books : (1) authors(s), (2) chapter title, (3) title of book, (4) editor(s), (5) city of publication, (6) publisher, (7) year of publication, (8) specific pages. Example : Binnie, C. , Jeavsons , .M. Photosensitive epilepsies. In : Epileptic syndromes in infancy, childhood and adolescence , eds. J.Roger, M. Bureau, Ch.Dravet, F.E. Dreifuss, A.Perret , P.Wolf. London, John Libbey & Company, Ltd, 1992, 299-305. The articles are considered for publication on the understanding that the presented material has not been published or is being submitted elsewhere before appearing in BULGARIAN NEUROLOGY. Authors should indicate that ethical approval of the study was granted and that informed consent was given. All authors should approve and sign the final manuscript. Manuscript with one copy (or a diskette and a copy) should be sent to the following address: Sofia 1504, Bulgaria, 8, Bialo more str. Department of Neurology University Hospital ◊ Queene Jovanna“: Prof. P. Stamenova


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology ëöÑöêÜÄçàÖ

CONTENTS

éÅáéêà

REVIEWS

ïàêìêÉàü çÄ ÖèàãÖèëàüíÄ – àçÑàäÄñàà à ÇöáåéÜçéëíà (I) èÂÚfl ÑËÏÓ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

EPILEPTIC SURGERY – INDICATIONS AND POSSIBILITIES (I) Petia Dimova . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

ïàêìêÉàü çÄ ÖèàãÖèëàüíÄ èêÖïàêìêÉàóçÄ ÑàÄÉçéëíàäÄ (II) èÂÚfl ÑËÏÓ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

EPILEPSY SURGERY - PRESURGICAL EVALUATION (II) Petia Dimova . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

îÄêåÄäéàäéçéåàäÄ à ÖèàãÖèëàü è. Ň··‡ÌÓ‚, á. á‡ı‡Ë‚ . . . . . . . . . . . . . . . . . . .63

PHARMACOECONOMICS AND EPILEPSY P.Balabanov, Z.Zahariev . . . . . . . . . . . . . . . . . . . . .63

çÖÇêéçéèêéíÖäñàü ëöë CITICOLINE èêà àëïÖåàóçà åéáöóçà àçëìãíà à óÖêÖèçéåéáöóçà íêÄÇåà è. ëÚ‡ÏÂÌÓ‚‡, å. åË·ÌÓ‚‡, Ñ. Äڇ̇ÒÓ‚‡, å. ꇉ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

NEUROPROTECTION WITH CITICOLINE IN PATIENTS WITH ISCHEMIC STROKES AND BRAIN INJURIES P. Stamenova, M. Milanova, D. Atanasova, M. Radeva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

ëäêàçàçÉéÇà çÖÇêéèëàïéãéÉàóçà íÖëíéÇÖ áÄ äéÉçàíàÇçà çÄêìòÖçàü à ÑÖåÖçñàü à. ÑËÏËÚÓ‚, ç. ÑÂ΂‡,ã. í‡ÈÍÓ‚ . . . . . . . . . . .74

NEUROPSYCHOLOGICAL SCREENING TESTS FOR COGNITIVE IMPAIRMENT AND DEMENTIA I. Dimitrov, N. Deleva, L. Traykov . . . . . . . . . . . . . .74

éêàÉàçÄãçà ëíÄíàà

ORIGINAL PAPERS

ãÖäà äéÉçàíàÇçà çÄêìòÖçàü èêà èÄñàÖçíà ë èÄêäàçëéçéÇÄ ÅéãÖëí å. èÂÚÓ‚‡, å. ê‡È˜Â‚‡, ü. ÜÂ΂ , ã. í‡ÈÍÓ‚ . .77

MILD COGNITIVE IMPAIRMENT IN PATIENTS WITH PARKINSON’S DESEASE M. Petrova, M. Raycheva, Y. Zhelev, L. Traykov . . . .77

åàçàåÄãçÄ óÖêçéÑêéÅçÄ ÖçñÖîÄãéèÄíàü èêà èÄñàÖçíà ë óÖêçéÑêéÅçÄ ñàêéáÄ è. Äڇ̇ÒÓ‚‡, ç. ä¸ÒÚ‚, ê. å‡Ò‡Î‰ÊË‚‡, ä. Ňı˜Â‚‡ÌÓ‚, Ä. åËı‡ÈÎÓ‚‡, É. åÛÁË͇‰ÊË‚‡, ï. è‡ÛÌÓ‚‡, å. äÓÒÚ‡‰ËÌÓ‚‡, Ñ. ÉÂÓ„Ë‚ . . . . . . .80

MINIMAL HEPATIC ENCEPHALOPATHY IN PATIENTS WITH LIVER CIRRHOSIS

ìãíêÄáÇìäéÇé ÑìèãÖäë-ëäÖçàêÄçÖ çÄ ëöççàíÖ ÄêíÖêàà èêà Åéãçà ëöë áÄïÄêÖç ÑàÄÅÖí à ÑàÄÅÖíçÄ èéãàçÖÇêéèÄíàü è. чÏflÌÓ‚, ç. ÑËÏ.ÑËÏËÚÓ‚, ç. ÑÓÍ.ÑËÏËÚÓ‚, ã. á‡ÔflÌÓ‚‡, Ç. ÑËÏËÚÓ‚‡, Ñ. ÅÓ„‰‡ÌÓ‚‡, à. ÇÂΘ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

ULTRASAOUND DUPLEX-SCANNING OF THE CAROTID ARTERIES IN PATIENTS WITH DIABETES MELLITUS AND DIABETIC NEUROPATHIY P. Damianov, N. Dim.Dimitrov, N. Doc. Dimitrov, L. Zaprianova, V. Dimitrova, D. Bogdanova, I.Velcheva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84

íêÄçáàíéêçÄ ÉãéÅÄãçÄ ÄåçÖáàü û. èÂÚÓ‚‡, ã. í‡ÈÍÓ‚, à. í˙Ì‚, å. äÛÔ‚, Å. åË΂ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

TRANSIENT GLOBAL AMNESIA H. Petrova, L. Trajkov, I. Tarnev, M. Krupev, B. Milev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88

àáåÖêÇÄçÖ çÄ ÇêÖåÖÇàíÖ èÄêÄåÖíêà çÄ ÇÄêàÄÅàãçéëííÄ çÄ ëöêÑÖóçÄíÄ óÖëíéíÄ èêà 2 íàè ÑàÄÅÖíàñà Ç ìëãéÇàüíÄ çÄ éêíéíÖëí à. ÑÓÏÛҘ˂ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

MEASUREMENT OF TIME-DOMAIN PARAMETERS OF HEART RATE VARIABILITY IN TYPE 2 DIABETICS IN CONDITIONS OF ORTHOTEST I. Domuschiev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90

éèàëÄçàÖ çÄ äãàçàóçà ëãìóÄà

CASE REPORT

TêÖíàóÖç åÖçàçÉéÇÄëäìãÄêÖç çÖÇêéãìÖë – éèàëÄçàÖ çÄ äãàçàóÖç ëãìóÄâ à ãàíÖêÄíìêÖç éÅáéê å. äÎËÒÛÒÍË, ç. íÓÚ‚‡, å. чÒ͇ÎÓ‚, ñ. ñ‡ÌÍÓ‚‡ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

MENINGOVASCULAR NEUROSYPHILIS – A CASE REPORT

P. Atanassova, N. Krustev, R. Massaldjieva, K. Bahchevanov, A. Michajlova, G. Muzikadjieva, H. Paunova, M. Kostadinova, D. Georgiev . . . . . . . .80

M. Klissurski, N. Toteva, M. Daskalov, T. Tsankova . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

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é·ÁÓ ïàêìêÉàü çÄ ÖèàãÖèëàüíÄ – àçÑàäÄñàà à ÇöáåéÜçéëíà (I) èÂÚfl ÑËÏÓ‚‡ ÑÂÚÒ͇ Ì‚ÓÎӄ˘̇ ÍÎËÌË͇, ìëÅÄãçè “ë‚.ç‡ÛÏ” – ëÓÙËfl SUMMARY EPILEPTIC SURGERY – INDICATIONS AND POSSIBILITIES (I) Petia Dimova Thanks to contemporary neuroimaging techniques and the use of invasive electrophysiology for the localization of epileptogenic foci, increasingly more patients with partial epilepsies can be treated surgically. The results of such neurosurgical interventions are very good, particularly in mesial temporal lobe epilepsy. Recently, good results (60% to 70% seizure freedom) have also been achieved in extratemporal resections. Therefore, the epileptic surgery after careful candidate selection and precise presurgical evaluation becomes a main treatment for patients with refractory epilepsies. KEY WORDS: epilepsy, extratemporal, refractory, surgery, temporal. êÖáûåÖ Å·„Ó‰‡ÂÌË ̇ Ò˙‚ÂÏÂÌÌËÚ Ì‚ÓËÁÓ·‡Áfl‚‡˘Ë ÚÂıÌËÍË Ë ÔË·„‡ÌÂÚÓ Ì‡ ËÌ‚‡ÁË‚ÌË ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ÏÂÚÓ‰Ë Á‡ ÎÓ͇ÎËÁ‡ˆËfl ̇ ÂÔËÎÂÔÚÓ„ÂÌÌËÚ ӄÌˢ‡, ‚Ò Ôӂ˜ ԇˆËÂÌÚË Ò ÙÓ͇ÎÌË ÂÔËÎÂÔÒËË ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÎÂÍÛ‚‡ÌË ıËÛ„˘ÌÓ. êÂÁÛÎÚ‡ÚËÚ ÓÚ Ì‚ÓıËÛ„˘ÌËÚ ËÌÚÂ‚Â̈ËË Ò‡ ÏÌÓ„Ó ‰Ó·Ë, ÓÒÓ·ÂÌÓ ÔË ÂÔËÎÂÔÒËfl Ò ÏÂÁˇÎ̇ ÚÂÏÔÓ‡Î̇ ÒÍÎÂÓÁ‡. Ç ÔÓÒΉÌËÚ „Ó‰ËÌË ‰Ó·Ë ÂÁÛÎÚ‡ÚË (60-70% Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË) Ò ÔÓÒÚË„‡ Ë ÔË ÂÍÒÚ‡ÚÂÏÔÓ‡ÎÌË ÂÁÂ͈ËË. èÓ‡‰Ë ÚÓ‚‡, ıËÛ„˘ÌÓÚÓ Î˜ÂÌË ̇ ÂÔËÎÂÔÒËflÚ‡ ÒΉ ÔˆËÁÂÌ ÔÓ‰·Ó Ë ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚˇ ̇ ͇̉ˉ‡ÚËÚ ÒÚ‡‚‡ ÓÒÌÓ‚ÌÓ Î˜ÂÌË ÔË Ô‡ˆËÂÌÚË Ò ÂÙ‡ÍÚÂÌË ÂÔËÎÂÔÒËË. äãûóéÇà Ñìåà: ÂÔËÎÂÔÒËfl, ÂÍÒÚ‡ÚÂÏÔÓ‡Î̇, ÂÙ‡ÍÚÂ̇, ÚÂÏÔÓ‡Î̇, ıËÛ„Ëfl. ÇöÇÖÑÖçàÖ ÖÔËÎÂÔÚ˘̇ڇ ıËÛ„Ëfl Ôˉӷ˂‡ ‚Ò ÔÓ-„ÓÎflÏÓ Á̇˜ÂÌË ͇ÚÓ ÏÂÚÓ‰ Á‡ ΘÂÌË ̇ ÂÔËÎÂÔÒËË, ÂÁËÒÚÂÌÚÌË Í˙Ï ÚÂ‡ÔËflÚ‡ Ò ‡ÌÚËÂÔËÎÂÔÚ˘ÌË Ï‰Ë͇ÏÂÌÚË (ÄÖå). èÂ‰Ë Ô‡ˆËÂÌÚ˙Ú ‰‡ ·˙‰Â ̇ÒÓ˜ÂÌ Á‡ Ì‚ÓıËıÛ„˘ÌÓ Î˜ÂÌËÂ, ÒΉ‚‡ ‰‡ ·˙‰Â ‚ÌËχÚÂÎÌÓ ÛÚÓ˜ÌÂÌ, ‰‡ÎË Â ÔÓ‰ıÓ‰fl˘ Á‡ ڇ͇‚‡ ÚÂ‡ÔËfl. à ‰ÓÒ„‡ ‚‡Ê‡Ú ‚˙‚‰ÂÌËÚ ÔÂÁ 1974 „. ÓÚ Walker ÍËÚÂËË (26): 1. ífl·‚‡ ‰‡ Ò ËÁÍβ˜Ë ÔÓ„ÂÒË‚ÌÓ Ì‚ÓÎӄ˘ÌÓ Á‡·ÓÎfl‚‡Ì (̇Ô. ÏÌÓÊÂÒÚ‚Â̇ ÒÍÎÂÓÁ‡, ÁÎÓ͇˜ÂÒÚ‚ÂÌ ÚÛÏÓ, ÏÓÁ˙˜ÂÌ ‚‡ÒÍÛÎËÚ, Ì‚ÓÏÂÚ‡·ÓÎËÚÌË Ë ÔÓ„ÂÒË‚ÌË ‰Â„ÂÌÂ‡ÚË‚ÌË Á‡·ÓÎfl‚‡ÌËfl). èÓ‡‰Ë ÚÓ‚‡, ÂÁÂ͈ËËÚ ̇ ÁÎÓ͇˜ÂÒÚ‚ÂÌË ÏÓÁ˙˜ÌË ÚÛÏÓË, ÍÓËÚÓ ˜ÂÒÚÓ Ò χÌËÙÂÒÚË‡Ú Ò ÂÔËÎÂÔÚ˘ÌË ÔËÒÚ˙ÔË, Ì Ò ÔËÂÏ‡Ú Á‡ ıËÛ„Ëfl ̇ ÂÔËÎÂÔÒËflÚ‡ sensu strictu, ‡ ÒΉ‚‡ ‰‡ ·˙‰‡Ú ÓÁ̇˜‡‚‡ÌË Í‡ÚÓ ÚÛÏÓ̇ ıËÛ„Ëfl. 2. î‡χÍÓÎӄ˘̇ڇ ÂÁËÒÚÂÌÚÌÓÒÚ Úfl·‚‡ ‰‡ ·˙‰Â ‰Ó͇Á‡Ì‡. íÛÍ Â ‚‡ÊÌÓ ÄÖå ‰‡ ·˙‰‡Ú ‰ÓÁË‡ÌË ‰Ó Ú.̇. ◊ÒÛ·ÂÍÚ˂̇ „‡Ìˈ‡ ̇ ËÌÚÓÍÒË͇ˆËfl”. Ç ‰ÓÔ˙ÎÌÂÌËÂ, ÓÒ‚ÂÌ ÔÓÌ ‰‚ ÏÓÌÓÚÂ‡ÔËË, Úfl·‚‡ ‰‡

Ò‡ ·ËÎË ÓÔËÚ‚‡ÌË Ë ÍÓÏ·Ë̇ˆËË ÓÚ ÄÖå. 3. èÓ‰˙ÎÊËÚÂÎÌÓÒÚÚ‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ Úfl·‚‡ ‰‡  ÔÓÌ 1 ‰Ó 2 „Ó‰ËÌË, ͇ÚÓ ÚÛÍ Ò‡ ‚˙ÁÏÓÊÌË ËÁÍβ˜ÂÌËfl (̇Ô. ‰Ó·Ó͇˜ÂÒÚ‚ÂÌ ÚÛÏÓ ËÎË ÚÛÏÓ ̇ ‡Á‚ËÚËÂÚÓ Í‡ÚÓ Ô˘Ë̇ Á‡ ÂÔËÎÂÔÒËflÚ‡). 4. ÖÔËÎÂÔÚ˘ÌËÚ ÔËÒÚ˙ÔË Ò‡ Á̇˜ËÚÂÎÌÓ ËÌ‚‡ÎˉËÁË‡˘Ë Âʉ̂̇ڇ ‰ÂÈÌÓÒÚ Ì‡ Ô‡ˆËÂÌÚ‡. ç‡ÔËÏÂ, Ë̉Ë͇ˆËfl Á‡ ıËÛ„˘ÌÓ Î˜ÂÌË ÔË ÂÔËÎÂÔÒËfl, ÍÓflÚÓ Ò ÔÓÚ˘‡ Ò‡ÏÓ Ò˙Ò ÒÂÚË‚ÌË ÔËÒÚ˙ÔË, Úfl·‚‡ ‰‡ ·˙‰Â ÏÌÓ„Ó ÔÓÒÚ‡‚Â̇ Ò ÏÌÓ„Ó ÂÁÂ‚Ë. 5.臈ËÂÌÚ˙Ú Úfl·‚‡ ‰‡ ·˙‰Â ÏÓÚË‚Ë‡Ì Á‡ ÌÂÓ·ıÓ‰ËÏËÚ ÔÂıËÛ„˘ÌË ËÁÒΉ‚‡ÌËfl. íÓÈ Úfl·‚‡ ‰‡  ̇flÒÌÓ, ˜Â ‚ Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë Ë ÒΉ ÓÔÂ‡ˆËflÚ‡ Ò ̇·„‡ ÔËÂÏ Ì‡ ÄÖå. 6. äÓÂÙˈËÂÌÚ Ì‡ ËÌÚÂÎË„ÂÌÚÌÓÒÚ, ÔÓ-χÎ˙Í ÓÚ 70, Ó·ËÍÌÓ‚ÂÌÓ Ì‡ÒÓ˜‚‡ Í˙Ï ‰ËÙÛÁÌÓ ÏÓÁ˙˜ÌÓ Û‚Âʉ‡ÌÂ. ë˙ÓÚ‚ÂÚÌÓ Ì‡ ÚÓ‚‡, ÔË ÚÂÁË Ô‡ˆËÂÌÚË ÂÙÂÍÚË‚ÌÓÒÚÚ‡  ÔÓ-χÎ͇, ÔÓ‡‰Ë ÍÓÂÚÓ Ë̉Ë͇ˆËflÚ‡ Á‡ ıËÛ„˘ÌÓ Î˜ÂÌË ̇ ÂÔËÎÂÔÒËflÚ‡ Úfl·‚‡ ‰‡ ·˙‰Â ÔÓÒÚ‡‚Â̇ ÏÌÓ„Ó ‚ÌËχÚÂÎÌÓ. 7. èÒËıˇÚ˘ÌËÚ Á‡·ÓÎfl‚‡ÌËfl ÔÓ ÔË̈ËÔ Ò‡ ÔÓÚË‚ÓÔÓ͇Á‡ÌË Á‡ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl. ÄÍÓ Ô‡ˆËÂÌÚ˙Ú ÓÒÚ‡‚‡ ͇̉ˉ‡Ú Á‡ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl ÒΉ ÛÒÔ¯ÌË ÔÂıËÛ„˘ÌË ËÁÒΉ‚‡ÌËfl Ë Ò‡ ËÁÔ˙ÎÌÂÌË „ÓÂÔÓÒÓ˜ÂÌËÚ ÍËÚÂËË, Úfl·‚‡ ‰‡ Ò ÓÔ‰ÂÎË ÓÔÚËχÎ̇ڇ Ì‚ÓıËÛ„˘̇ ËÌÚÂ‚Â̈Ëfl. íÓ‚‡ Ò ÔÓÒÚË„‡ ÔË Ë̉˂ˉۇÎÂÌ Á‡ Ô‡ˆËÂÌÚ‡ ÔÓ‰ıÓ‰ Ë ‚ ıÓ‰‡ ̇ ËÌÚÂ‰ËÒˆËÔÎË̇ÌÓ Ó·Ò˙ʉ‡Ì ÓÚ ÂÔËÎÂÔÚÓÎÓÁË, Ì‚ÓÔÒËıÓÎÓÁË, ÔÒËıˇÚË Ë Ì‚ÓıËÛÁË (26). ïËÛ„˘ÌËÚ ËÌÚÂ‚Â̈ËË ÔË ÂÔËÎÂÔÒËfl Ò ÓÔ‰ÂÎflÚ ÒÔÓ‰ Ë̉Ë͇ˆËËÚ Á‡ ÓÔÂ‡ˆËfl, ̇ıÓ‰ÍËÚ ÓÚ Ì‚Ó‡‰ËÓÎӄ˘ÌËÚ ËÎË Ô‡ÚÓÎӄ˘ÌËÚ ËÁÒΉ‚‡ÌËfl, ÓÔÂ‡ÚË‚ÌËfl ÏÂÚÓ‰ Ë Ó·Âχ ̇ ÂÁÂ͈Ëfl, ͇ÚÓ Ú ÒÔ‡‰‡Ú Í˙Ï ÒΉÌËÚ ͇Ú„ÓËË: ● éÔÂ‡ˆËËÚ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ‡Á‰ÂÎÂÌË ÒÔÓ‰ Ë̉Ë͇ˆËflÚ‡ ̇ ͇ÛÁ‡ÎÌË (ÍÛ‡ÚË‚ÌË) ËÎË Ô‡ÎˇÚË‚ÌË. ä‡ÛÁ‡ÎÌËÚ ÓÔÂ‡ˆËË ËÏ‡Ú Á‡ ˆÂÎ ÓÚÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ ÂÔËÎÂÔÚÓ„ÂÌÌÓÚÓ Ó„ÌˢÂ, ڇ͇ ˜‡ ‰‡ Ò ÔÓÒÚË„Ì ҂ӷӉ‡ ÓÚ ÔËÒÚ˙ÔË. è‡ÎˇÚË‚ÌËÚ ÓÔÂ‡ˆËË (̇Ô. ͇ÎÓÁÓÚÓÏËfl) ˆÂÎflÚ ÔÂÍ˙Ò‚‡Ì ̇ ‡ÁÔÓÒÚ‡ÌÂÌËÂÚÓ Ì‡ ÔËÒÚ˙ÔËÚ ÓÚ ‚‡ÊÌËÚ ÔÓ‚Ó‰ÌËÍÓ‚Ë ÒËÒÚÂÏË, ËÎË ÓÚÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ ‚ÚÓ˘ÌË ÂÔËÎÂÔÚÓ„ÂÌÌË „ÂÌÂ‡ÚÓË. èË ÚÂÁË ËÌÚÂ‚Â̈ËË ÂÁÛÎÚ‡ÚÌÓÒÚÚ‡ Ì  ÚÓÎÍÓ‚‡ ‰Ó·‡, ÍÓÎÍÓÚÓ ÔË Í‡ÛÁ‡ÎÌËÚÂ. ● à̉Ë͇ˆËflÚ‡ ‚˙Á ÓÒÌÓ‚‡ ̇ Ô‡ÚÓÎӄ˘ÌË ËÎË ‡‰ËÓÎӄ˘ÌË Ì‡ıÓ‰ÍË ÏÓÊ ‰‡ ÓÔ‰ÂÎfl ÎÂÁËÓÌÌË Ë ÌÂ-ÎÂÁËÓÌÌË ÓÔÂ‡ˆËË. ÑÓ͇ÚÓ ÔË Ô˙‚ËÚ Ò ÓÚÒÚ‡Ìfl‚‡ ‡‰ËÓÎӄ˘ÌÓ ‰Ó͇Á‡Ì‡ ÒÚÛÍÚÛ‡ (ËÁ‚˙¯‚‡ Ò Ú. ̇. ÎÂÁËÓÌÂÍÚÓÏËfl), ÔË ‚ÚÓËÚ Ò ÓÔÂË‡Ú Ô‡ˆËÂÌÚË Ò ÌÓχÎ̇ χ„ÌËÚÌÓ-ÂÁÓ̇Ò̇ ÚÓÏÓ„‡ÙÒ͇ (åêí) ̇ıӉ͇. èË Ú‡ÁË ‚ÚÓ‡ „ÛÔ‡ Ô‡ˆËÂÌÚË ÓÔÂ‡ÚË‚ÌËÚ ÂÁÛÎÚ‡ÚË Ò‡ Ó·ËÍÌÓ‚ÂÌÓ ÔÓ-ÎÓ¯Ë. éÔÂ‡ˆËËÚ Ò ‡Á‰ÂÎflÚ Ë Ì‡ ÂÁÂÍÚË‚ÌË Ë ÌÂ-ÂÁÂÍÚË‚ÌË (‰ËÒÍÓÌÂÍÚË‚ÌË). èË ÂÁÂÍÚË‚ÌËÚ Ò ÓÚÒÚ‡Ìfl‚‡ Ú˙Í‡Ì (̇Ô. ÎÂÁËÓÌÂÍÚÓÏËË ËÎË ‡ÏË„‰‡ÎÓ-ıËÔÓ͇ÏÔÂÍÚÓÏËË). ä˙Ï ÌÂ-ÂÁÂÍÚË‚ÌËÚ ÒÔ‡‰‡Ú ͇ÎÓÁÓÚÓÏË-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ËÚÂ Ë ÏÌÓÊÂÒÚ‚Â̇ڇ ÒÛ·ÔˇÎ̇ Ú‡ÌÒÂ͈Ëfl. àÏÔ·ÌÚ‡ˆËflÚ‡ ̇ ‚‡„ÛÒ-ÌÂ‚ ÒÚËÏÛ·ÚÓ Ò˙˘Ó  ÌÂ-ÂÁÂÍÚË‚ÂÌ ÔÓ‰ıÓ‰. ç‡Í‡fl, ÓÔÂ‡ˆËËÚ Ò ‡Á΢‡‚‡Ú Ë ÒÔÓ‰ Ó·Âχ ̇ ÂÁÂ͈Ëfl Ë ÓÔÂ‡Ú˂̇ڇ ÏÂÚÓ‰Ë͇: Ëχ ÓÔÂ‡ˆËË, ÍÓËÚÓ Ò ӄ‡Ì˘‡‚‡Ú ÒÚÓ„Ó ‚˙ıÛ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇ (̇Ô. Ë̉˂ˉۇÎÌÓ ÔËÒÔÓÒÓ·Â̇ ÙÓÌÚ‡Î̇ ÍÓÚÂÍÚÓÏËfl). àχ Ë Òڇ̉‡ÚËÁË‡ÌË ÂÁÂ͈ËË Í‡ÚÓ Ô‰̇ڇ 2/3 ÚÂÏÔÓ‡Î̇ ÂÁÂ͈Ëfl, ˜ËÈÚÓ Ó·ÂÏ Â ÌÂÁ‡‚ËÒËÏ ÓÚ ÂÔËÎÂÔÚÓ„ÂÌÌÓÚÓ Ó„ÌˢÂ. ÖÒÚÂÒÚ‚ÂÌÓ, ‰ÌÂÒ Ò ÓÔËÚ‚‡ χÍÒËχÎÌÓ Ó„‡Ì˘‡‚‡Ì ̇ ÂÁÂ͈ËflÚ‡, ÌÓ ·ÂÁ ‰‡ Ò ̇·„‡ ÂÓÔÂ‡ˆËfl. èÓ-̇‰ÓÎÛ Ò‡ Ô‰ÒÚ‡‚ÂÌË Ì‡È-˜ÂÒÚËÚ ıËÛ„˘ÌË ËÌÚÂ‚ˆËË ÔË ÂÔËÎÂÔÒËfl. êÖáÖäñàà çÄ íÖåèéêÄãçàü Ñüã éÚÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ ÚÂÏÔÓ‡ÎÌËfl ‰flΠ ̇È-˜ÂÒÚ‡Ú‡ Ë ÛÒÔ¯̇ ÓÔÂ‡ˆËfl Á‡ ΘÂÌË ̇ ÂÔËÎÂÔÒËfl. ᇠËÁÏË̇ÎËÚ ÌflÍÓÎÍÓ ‰ÂÒÂÚËÎÂÚËfl Ò‡ Ò ‡Á‚ËÎË ‰‚‡ ÓÔÂ‡ÚË‚ÌË ÔÓ‰ıÓ‰‡: Òڇ̉‡ÚËÁË‡Ì‡ 2/3 Ô‰̇ ÚÂÏÔÓ‡Î̇ ÂÁÂ͈Ëfl Ë Ë̉˂ˉۇÎÌÓ ÓÔ‰ÂÎÂ̇ڇ ÚÂÏÔÓ‡Î̇ ÍÓÚÂÍÚÓÏËfl. ç‡È-˜ÂÒÚËflÚ ÏÂÚÓ‰  Ô‰̇ڇ 2/3 ÚÂÏÔÓ‡Î̇ ÂÁÂ͈Ëfl, ͇ÚÓ ÔË·„‡Ì‡Ú‡ ÚÂıÌË͇ Ò ‡Á΢‡‚‡ ‚ ÓÚ‰ÂÎÌËÚ ˆÂÌÚÓ‚Â. çflÍÓË Ì‚ÓıËÛÁË Ô‰ÔÓ˜ËÚ‡Ú en bloc ÂÁÂ͈Ëfl ̇ ÚÂÏÔÓ‡ÎÌËfl ‰flÎ ÔÓ Falconer, ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ ÒÚ‡Ì‡Ú‡ ̇ ÓÔÂ‡ˆËflÚ‡ (ÔÓ-χÎÍË ÂÁÂ͈ËË ÓÚ ˜‚Ó-‰ÓÏË̇ÌÚ̇ڇ ÒÚ‡Ì‡). í‡Í‡ ‡ÏË„‰‡Î‡Ú‡ Ë ıËÔÓ͇ÏÔ˙Ú Ò ÂÁˆË‡Ú ̇Ô˙ÎÌÓ ËÎË ˜‡ÒÚ˘ÌÓ. Ç ‰Û„Ë ˆÂÌÚÓ‚Â Ò ËÁ„ÓÚ‚flÚ Ë̉˂ˉۇÎÌË ÚÂÏÔÓ‡ÎÌË ÂÁÂ͈ËË. èÓÒÚ-ÓÔÂ‡ÚË‚ÌËÚ ÂÁÛÎÚ‡ÚË ÔË ÚÂÏÔÓ‡ÎÌË ÂÁÂ͈ËË ÔÓ͇Á‚‡Ú Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË ÔË ·ÎËÁÓ 80% ÓÚ Ô‡ˆËÂÌÚËÚ (9,10,11,22,28,39). èË ÓÍÓÎÓ 30% ÓÚ Ô‡ˆËÂÌÚËÚÂ Ò ÌÂÓÍÓÚË͇Î̇ ÚÂÏÔÓ‡Î̇ ÎÂÁËfl ÓÔÂ‡ÚË‚ÌËflÚ ÂÁÛÎÚ‡Ú ÏÓÊ ‰‡ ·˙‰Â ‚ÎÓ¯ÂÌ ÓÚ Â‰ÌÓ‚ÂÏÂÌÌÓÚÓ Ì‡Î˘Ë ̇ ıËÔÓ͇ÏÔ‡Î̇ ÒÍÎÂÓÁ‡ (◊dual pathology“) (10,20). íÂÊÍËÚ ÛÒÎÓÊÌÂÌËfl ÔË Òڇ̉‡ÚËÁË‡ÌËÚ 2/3 Ô‰ÌË ÚÂÏÔÓ‡ÎÌË ÂÁÂ͈ËË Ò‡ ‰ÍË. ç‡È-˜ÂÒÚËÚ ÛÒÎÓÊÌÂÌËfl Ò‡ Í‚‡‰‡ÌÚ‡ÌÓÔÒËfl (ÔË >50% ÓÚ Ô‡ˆËÂÌÚËÚÂ), ıÂÏˇÌÓÔÒ˘ÌË ‰ÂÙˈËÚË ‚ ÁËÚÂÎÌÓÚÓ ÔÓÎÂ, ÔÂıӉ̇ ËÎË ÔÓÒÚÓflÌ̇ ıÂÏËÔ‡ÂÁ‡, ËÌÙÂ͈ËË Ë ÂÔˉÛ‡ÎÌË ıÂχÚÓÏË, ÔÂıÓ‰ÌË Ô‡ÂÁË Ì‡ ÓÍÛÎÓÏÓÚÓËÛÒ ËÎË ÚÓı·ËÒ, ÔÂıӉ̇ ‡ÌÓÏËfl (ÔË > 20%), ÔÂχÌÂÌÚ̇ ‰ËÒÙ‡ÁËfl, „ÎÓ·‡ÎÌË Ô‡ÏÂÚÓ‚Ë ‰ÂÙˈËÚË), ÔÂıÓ‰ÌË ÔÒËıÓÁË ËÎË ‰ÂÔÂÒËË (28). ëÏ˙ÚÌÓÒÚÚ‡ ÔË ÚÂÁË ËÌÚÂ‚Â̈ËË Â ÔÓ-χÎ͇ ÓÚ 1% (28). ëÖãÖäíàÇçÄ ÄåàÉÑÄãéïàèéäÄåèÖäíéåàü èË ÏÂÁˇÎ̇ڇ ÚÂÏÔÓ‡Î̇ ÂÔËÎÂÔÒËfl (MTLE), ̇ȘÂÒÚ‡Ú‡ ÙÓχ ̇ ÙÓ͇Î̇ ÂÔËÎÂÔÒËfl, ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌËÚ ËÁÒΉ‚‡ÌËfl ÔÓ͇Á‚‡Ú, ˜Â ËÍÚ‡ÎÌËÚ ‡Áfl‰Ë Ò „ÂÌÂË‡Ú Ô‰ËÏÌÓ ‚ ıËÔÓ͇ÏÔ‡, ÌÓ Ò˙˘Ó Ë ‚ Ô‡‡ıËÔÓ͇ÏÔ‡ Ë ‡ÏË„‰‡Î‡Ú‡. íÓ‚‡  ‰Ó‚ÂÎÓ ‰Ó Òı‚‡˘‡ÌÂÚÓ, ˜Â ÓÚÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ ÚÂÁË ÒÚÛÍÚÛË ˘Â ‰Ó‚‰ ‰Ó ÔÓÒÚÓÔÂ‡Ú˂̇ Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË. èÂÁ 1975 „. Gazi Yasargil ‡Á‚Ë‚‡ ‚ ñ˛Ëı ÒÂÎÂÍÚ˂̇ڇ ‡ÏË„‰‡ÎÓ-ıËÔÓ͇ÏÔÂÍÚÓÏËfl (SAHE) ˜ÂÁ Ú‡ÌÒ-ÒË΂Ë‚ ‰ÓÒÚ˙Ô. èÂıËÛ„˘̇ڇ ÂÔËÎÂÔÚ˘̇ ‰Ë‡„ÌÓÒÚË͇  ‡Á‚ËÚ‡ ÓÚ ÂÔËÎÂÔÚÓÎÓ„‡ Heinz-Gregor Wieser (41). èË ÚÓÁË ÏÂÚÓ‰ ÒΉ ̇˜‡ÎÌÓ ÓÚÒÚ‡Ìfl‚‡Ì ̇ ‡ÏË„‰‡Î‡Ú‡ Ò ÂÁˆË‡ Ë Ô‰̇ڇ ˜‡ÒÚ Ì‡ ıËÔÓ͇ÏÔ‡ Ë ˜‡ÒÚ ÓÚ Ô‡‡ıËÔÓ͇ÏÔ‡. Ç ÂÚÓÒÔÂÍÚË‚ÌÓ ÔÓÛ˜‚‡Ì ̇ 369 Ô‡ˆËÂÌÚË Ò SAHE Ë ÔÂËÓ‰ ̇ ÔÓÒΉfl‚‡Ì ÏËÌËÏÛÏ 12 ÏÂÒˆ‡ 67% Ò‡ ·ËÎË ·ÂÁ ÔËÒÚ˙ÔË ËÎË Ò‡ ËχÎË Ò‡ÏÓ ‡ÛË; 11% Ò‡ ËχÎË ‰Ó 12 ÔËÒÚ˙Ô‡ „Ӊ˯ÌÓ, 15% Ò‡ ·ËÎË Ò ‰Û͈Ëfl ̇ ÔËÒÚ˙ÔËÚ ÏËÌËÏÛÏ 90%, ‡ 8% Ò‡ ·ËÎË ·ÂÁ Ò˙˘ÂÒÚ‚ÂÌÓ ÔÓ‰Ó·ÂÌË (40). èÓ‰Ó·ÌË ÂÁÛÎÚ‡ÚË Ò ÓÚÍË‚‡Ú Ë ‚ ‰Û„Ë

57

ÔÓÛ˜‚‡ÌËfl, ÔË ÍÓËÚÓ Ò‡ ÔË·„‡ÌË ‡Á΢ÌË ÚÂıÌËÍË Ì‡ SAHE. è‰ËÍÚÓË Á‡ ‰Ó·Ë ÓÔÂ‡ÚË‚ÌË ÂÁÛÎÚ‡ÚË Ò‡ ‰Ó͇Á‚‡ÌÂÚÓ Ì‡ ÒÚÛÍÚÛ̇ ÎÂÁËfl, ‡Ì‡ÏÌÂÁ‡ Á‡ Ù·ËÎÌË „˙˜Ó‚Â Ë Ó·¯Ë̇ ÂÁÂ͈Ëfl ̇ ıËÔÓ͇ÏÔ‡ Ë ÓÒÓ·ÂÌÓ Ì‡ Ô‡‡ıËÔÓ͇ÏÔ‡. ä‡Ú͇ڇ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚ Ì‡ ÔËÒÚ˙ÔËÚÂ, ÎËÔÒ‡Ú‡ ̇ ÍÓÌÚ‡Î‡ÚÂ‡ÎÌÓ ÂÔËÎÂÔÚÓ„ÂÌÌÓ Ó„Ìˢ ËÎË Í˙Ò̇ ÔÓÔ‡„‡ˆËfl Í˙Ï ÍÓÌÚ‡Î‡ÚÂ‡Î̇ڇ ÒÚ‡Ì‡ Ò‡ ÓÔ‰ÂÎflÎË ÏÌÓ„Ó ‰Ó·Ë ÓÔÂ‡ÚË‚ÌË ÂÁÛÎÚ‡ÚË (40). ÖäëíêÄíÖåèéêÄãçà êÖáÖäñàà é·‡ÚÌÓ Ì‡ ˜ÂÒÚÓ ËÁ‚˙¯‚‡ÌËÚ Òڇ̉‡ÚËÁË‡ÌË Ô‰ÌË 2/3 ÚÂÏÔÓ‡ÎÌË ÂÁÂ͈ËË, ‰ÌÂÒ ÔÓ˜ÚË Ì Ò ËÁ‚˙¯‚‡ ÚÓÚ‡ÎÌÓ ÓÚÒÚ‡Ìfl‚‡Ì ̇ ÙÓÌÚ‡ÎÌËfl, Ô‡ËÂÚ‡ÎÌËfl ËÎË Ó͈ËÔËÚ‡ÎÌËfl ‰flÎ. ë˙‚ÂÏÂÌÌËÚ ÂÍÒÚ‡ÚÂÏÔÓ‡ÎÌË ıËÛ„˘ÌË ÚÂıÌËÍË Ò‡ Ô‰ËÏÌÓ ˜‡ÒÚ˘ÌË ÍÓÚÂÍÚÓÏËË, ÍÓËÚÓ Ò ӄ‡Ì˘‡‚‡Ú ‚˙ıÛ ÂÔËÎÂÔÚÓ„ÂÌÌÓÚÓ Ó„Ìˢ (9,19). èË Ô‡ˆËÂÌÚË Ò ‰Ó· ӄ‡Ì˘ÂÌË ÎÂÁËË Ò ÔÓÒÚË„‡ Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË ÔË ÓÍÓÎÓ 70% ÓÚ Ô‡ˆËÂÌÚËÚ (8,16,18). ãÓ͇ÎËÁ‡ˆËflÚ‡ ̇ Ú‡ÍË‚‡ ÎÂÁËË Ì ‚ÎËfl ‚˙ıÛ ÂÁÛÎÚ‡Ú‡, ‡ÍÓ Ó·ÂÏ˙Ú Ì‡ ÂÁÂ͈Ëfl Ì Ò ӄ‡Ì˘‡‚‡ ÓÚ ÙÛÌ͈ËÓ̇ÎÌË Ò˙Ó·‡ÊÂÌËfl. èÓ Ó·Ó·˘‡‚‡˘Ë ‰‡ÌÌË Ì‡ Sisodiya ÓÚ 2000 „., ÔË Ô‡ˆËÂÌÚË Ò ‰Ó· ӄ‡Ì˘ÂÌË ÎÂÁËË Í‡ÚÓ Ï‡ÎÙÓχˆËËÚ ̇ ÍÓÓ‚ÓÚÓ ‡Á‚ËÚË Ò ÔÓÒÚË„‡ ÔË·ÎËÁËÚÂÎÌÓ 47% Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË (32). èË ÙÓÌÚ‡ÎÌË ÂÔËÎÂÔÒËË Ò‡ ÛÒÚ‡ÌÓ‚ÂÌË ÌflÍÓÎÍÓ Ô‰ËÍÚÓ‡ Á‡ Ú‡Í˙‚ ÂÁÛÎÚ‡Ú (15,19,24), ͇ÚÓ „ÂÌÂ‡ÎËÁË‡Ì‡Ú‡ Ô‡ÓÍÒËÁχÎ̇ ‡ÍÚË‚ÌÓÒÚ ÔÓ‚ÎËfl‚‡ Ì„‡ÚË‚ÌÓ ÂÁÛÎÚ‡ÚËÚÂ. èË Ó͈ËÔËÚ‡ÎÌË ËÎË Ó·˘Ó ÔÓÒÚÂËÓÌË ÂÔËÎÂÔÒËË Â ÛÒÚ‡ÌÓ‚ÂÌÓ, ˜Â ‚ˉ˙Ú Ì‡ ÎÂÁËflÚ‡  ÓÔ‰ÂÎfl˘, ͇ÚÓ Ò‡ÏÓ 45% ÓÚ Ô‡ˆËÂÌÚËÚÂ Ò ‡·ÌÓÏÌÓÒÚË ‚ ÍÓÓ‚ÓÚÓ ‡Á‚ËÚË ËÏ‡Ú ÓÚ΢ÂÌ ËÎË ‰Ó·˙ ÒΉÓÔÂ‡ÚË‚ÂÌ ËÁıÓ‰ (5). ÑÂÙÂÍÚËÚ ‚ ÁËÚÂÎÌÓÚÓ ÔÓÎÂ, ̇ÔËÏÂ ıÓÏÓÌËÏ̇ ıÂÏˇÌÓÔÒËfl, Ò‡ ̇È-˜ÂÒÚÓÚÓ ÛÒÎÓÊÌÂÌË ÔË Ó͈ËÔËÚ‡ÎÌÓ-‰flÎÓ‚‡ ıËÛ„Ëfl. äÓÚË͇ÎÌËÚ ‰ËÒÔ·ÁËË Ò‡ Ò‚˙Á‡ÌË Ò ÔÓ-‰Ó·˙ ËÁıÓ‰, ÓÚÍÓÎÍÓÚÓ ÚÂÁË Ò ı‡Ï‡ÚÓÏË ËÎË ıÂÚÂÓÚÓÔËË. èË Ô‡ËÂÚ‡ÎÌË ÂÔËÎÂÔÒËË ÂÁÛÎÚ‡ÚÌÓÒÚÚ‡  ÒıӉ̇, ‡ ̇È-˜ÂÒÚËÚ ÛÒÎÓÊÌÂÌËfl Ò‡ ÔÂıÓ‰ÌË ËÎË ÔÂχÌÂÌÚÌË ÒÂÌÁÓÏÓÚÓÌË ‰ÂÙˈËÚË, ÎÂÍ ‡Ù‡Ú˘ÂÌ ÒË̉ÓÏ Ë ‚ÎÓ¯‡‚‡Ì ̇ ̇΢ÌË ÒÂÚË‚ÌË ‰ÂÙˈËÚË (16). Ç Ò‡‚ÌÂÌËÂ Ò Ô‡ˆËÂÌÚËÚ ·ÂÁ ‰Ó͇Á‡Ì‡ ÒÚÛÍÚÛ̇ ÎÂÁËfl, ÚÂÁË Ò ÏÓÙÓÎӄ˘ÌË ‡·ÌÓÏÌÓÒÚË Ò‡ Ò ÔÓ-„ÓÎflχ ‚ÂÓflÚÌÓÒÚ Á‡ Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË, ÓÒÓ·ÂÌÓ ‡ÍÓ ÔË ÎÂÁËÓÌÂÍÚÓÏËflÚ‡ Ò ËÁ‚˙¯‚‡ Ë ÂÁÂ͈Ëfl ̇ ÓÍÓÎ̇ڇ Ú˙Í‡Ì (2). ïËÛ„ËflÚ‡ ÔË Ô‡ˆËÂÌÚË Ò ÌÓχÎ̇ åêí, Ú.Â. ÔË ÌÂ-ÎÂÁËÓÌÌË ÂÔËÎÂÔÒËË, Ò˙˘Ó ÏÓÊ ‰‡ Ëχ ‰Ó·Ë ÔÓÒÚÓÔÂ‡ÚË‚ÌË ÂÁÛÎÚ‡ÚË (31). äÄãéáéíéåàü èÂÍ˙Ò‚‡ÌÂÚÓ (‡Á‰ÂÎflÌÂÚÓ) ̇ ÍÓÔÛÒ Í‡ÎÓÁÛÏ (͇ÎÓÁÓÚÓÏËfl) ‚ÂÓflÚÌÓ Â Ì‡È-‰Ó·ËflÚ ÔËÏÂ Á‡ ԇΡÚ˂̇ ıËÛ„˘̇ ËÌÚÂ‚Â̈Ëfl ÔË ÂÔËÎÂÔÒËfl. ä‡ÎÓÁÓÚÓÏËflÚ‡ Ëχ Á‡ ˆÂÎ ‰‡ ÔÂÍ˙ÒÌ ‚·Í̇ڇ, ÍÓËÚÓ Ò‡ ÓÚ„Ó‚ÓÌË Á‡ ‡ÁÔÓÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ ÔËÒÚ˙ÔËÚ ËÎË Á‡ ÏÂʉÛıÂÏËÒÙÂ̇ڇ ÔÓÔ‡„‡ˆËfl. èÂÍ˙Ò‚‡ÌÂÚÓ Ì‡ Òorpus callosum ÏÓÊ ‰‡ ·˙‰Â Ó„‡Ì˘ÂÌÓ ‚˙ıÛ Â‰Ì‡Ú‡ ÏÛ ÔÓÎÓ‚Ë̇ (Ô‰̇ ËÎË Á‡‰Ì‡) ËÎË ‰‡ ‡Ì„‡ÊË‡ Ô‰ÌËÚ 2/3 (̇È-˜ÂÒÚÓ); ÔË ÚÂÊÍË ÒÎÛ˜‡Ë, Ó·‡˜Â, ÏÓÊ ‰‡ Ò ‡Á‰ÂÎË ˆfl·ڇ ÒÚÛÍÚÛ‡. íÓ‚‡ Ò ËÁ‚˙¯‚‡ ÏÌÓ„Ó fl‰ÍÓ ‰ÌÂÒ, χ͇ ˜Â ÂÁÛÎÚ‡ÚËÚ ҇ ÔÓ-‰Ó·Ë, ÓÚÍÓÎÍÓÚÓ ÔË Ô‰̇ 2/3 ͇ÎÓÁÓÚÓÏËfl. êËÒÍ˙Ú ÓÚ ‰ËÒÍÓÌÂÍÚË‚ÂÌ ÒË̉ÓÏ Â ÔÓ-„ÓÎflÏ. à̉Ë͇ˆËË Á‡ ͇ÎÓÁÓÚÓÏËfl Ëχ ÔË Ññè Ò ıÂÏËÔ΄Ëfl Ë ÚÂÊ͇ ÂÔËÎÂÔÒËfl, ÒË̉Óχ ̇ Lennox-Gastaut Ë ÔË ÏÛÎÚËÙÓ͇ÎÌË, ‰‚ÛÒÚ‡ÌÌË ÂÔËÎÂÔÒËË (3,21,37). èÓ ÓÚ-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÌÓ¯ÂÌË ̇ ‚ˉӂÂÚ ÔËÒÚ˙ÔË, ÍÓËÚÓ Ò ÔÓ‚ËÎfl‚‡Ú ·Î‡„ÓÔËflÚÌÓ, ÚÓ‚‡ Ò‡ ÔÂ‰Ë ‚Ò˘ÍÓ ÂÔËÎÂÔÚ˘ÌËflÚ ÒÚ‡ÚÛÒ Ë "drop attacks" (‡ÚÓÌ˘ÌË ËÎË ÚÓÌ˘ÌË ÔËÒÚ˙ÔË). ä‡ÎÓÁÓÚÓÏËflÚ‡ ‚Ó‰Ë ‰Ó ÔÂÛÒÚ‡ÌÓ‚fl‚‡Ì ̇ ‰ÓÔ‡Ú‡ÍËÚ ÔË ÓÍÓÎÓ 70% ÓÚ Ô‡ˆËÂÌÚËÚÂ, ‡ ‰Ó 30% Ò‡ Ò˙Ò Á̇˜ËÚÂÎÌÓ ÔÓ‰Ó·ÂÌË (3,21,37). ïÖåàëîÖêÖäíéåàü à åìãíàãéÅÄêçà êÖáÖäñàà í ҇ ÚÂ‡Ô‚Ú˘ÌË ‚˙ÁÏÓÊÌÓÒÚË ÔË Ô‡ˆËÂÌÚË Ò ÏÌÓ„Ó ÚÂÊÍË (Ú.̇. ◊͇ڇÒÚÓÙ‡ÎÌË”) ÂÔËÎÂÔÒËË. ïÂÏËÒÙÂ‡Ú‡ ÏÓÊ ‰‡ ·˙‰Â ÓÚÒÚ‡ÌÂ̇ ‡Ì‡ÚÓÏ˘ÌÓ (ıÂÏËÒÙÂ̇ ÍÓÚÂÍÚÓÏËfl Ò˙Ò ËÎË ·ÂÁ ÓÚÒÚ‡Ìfl‚‡Ì ̇ ·‡Á‡ÎÌËÚ „‡Ì„ÎËË Ë Ò˙ı‡Ìfl‚‡Ì ̇ ıËÔÓڇ·ÏÛÒ‡ Ë ‰ËÂ̈ÂÙ‡ÎÓ̇) ËÎË ˜ÂÁ ‰ËÒÍÓÌÂ͈Ëfl ‰‡ Ò ËÁÍβ˜Ë ÙÛÌ͈ËÓ̇ÎÌÓ (12). ᇠÔ‰ÓÚ‚‡Úfl‚‡Ì ̇ ÔÓ‚˙ıÌÓÒÚ̇ڇ ÏÓÁ˙˜Ì‡ ıÂÏÓÒˉÂÓÁ‡ ͇ÚÓ ÚÂÊ͇ Í˙Ò̇ ÔÓÒΉˈ‡ ÓÚ ‡Ì‡ÚÓÏ˘̇ڇ ıÂÏËÒÙÂÂÍÚÓÏËfl Ò‡ ‡Á‚ËÚË ‰Û„Ë ÚÂıÌËÍË (1,7,12,13,25,38). èÓ̇ÒÚÓfl˘ÂÏ ÔÓÂ̈ÂÙ‡ÎÌËÚ ÍËÒÚË Ë ıÂÏËÏ„‡ÎÂ̈ÂÙ‡ÎËË, Ó·¯ËÌËÚ ÍÓÚË͇ÎÌË ‰ËÒÔ·ÁËË, Â̈ÂÙ‡ÎËÚ˙Ú Ì‡ Rasmussen Ë ÒË̉ÓÏ˙Ú Ì‡ Sturge-Weber Ò‡ Ë̉Ë͇ˆËËÚ Á‡ ÏÛÎÚËÎÓ·‡ÌË ÂÁÂ͈ËË Ë ıÂÏËÒÙÂÂÍÚÓÏËË. ïÂÏËÒÙÂÂÍÚÓÏËflÚ‡ Ò ËÁ‚˙¯‚‡ ÔÓ˜ÚË ËÁÍβ˜ËÚÂÎÌÓ ÔË Ô‡ˆËÂÌÚË Ò˙Ò Ò˙˘ÂÒÚ‚Û‚‡˘ Ì‚ÓÎӄ˘ÂÌ ‰ÂÙˈËÚ Í‡ÚÓ ıÂÏËÔ‡ÂÁ‡. èË Ú‡ÍË‚‡ Ô‡ˆËÂÌÚË ÏÓÊ ‰‡ Ò ÔÓÒÚË„Ì ҂ӷӉ‡ ÓÚ ÔËÒÚ˙ÔË ‚ ̇‰ 80% (17). éÔËÚ˙Ú Ì‡ The Cleveland Clinic, Johns Hopkins Hospital, UCLA Ë Miami Children's Hospital Ë ‰Û„Ë ˆÂÌÚÓ‚Â ÔÓ͇Á‚‡ ÓÚ΢ÌË ÂÁÛÎÚ‡ÚË ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÔËÒÚ˙ÔËÚ ‚ 50-70% ÓÚ Ô‡ˆËÂÌÚËÚ (13,17,25,36). é·˘Ó, ‰˙΄ÓÒÓ˜ÌËflÚ ÍÓÌÚÓΠ̇ ÔËÒÚ˙ÔËÚ  ÔÓ-ÎÓ¯ ÔË Ô‡ˆËÂÌÚË Ò Ï‡ÎÙÓχˆËË Ì‡ ÍÓÓ‚ÓÚÓ ‡Á‚ËÚËÂ. Ç˙ÔÂÍË ÔÓÒÓ˜ÂÌËÚ ÂÁÛÎÚ‡ÚË, Ë̉Ë͇ˆËflÚ‡ Á‡ ÚÂÁË Á̇˜ËÚÂÎÌË ÂÁÂÍÚË‚ÌË ËÌÚÂ‚Â̈ËË Úfl·‚‡ ‰‡ ·˙‰Â ÔÓÒÚ‡‚Â̇ ÏÌÓ„Ó Ô‰ԇÁÎË‚Ó Ë ÂÒÚÂÒÚ‚ÂÌÓ - ÒΉ ‚ÌËχÚÂÎ̇ Ô‰ÓÔÂ‡Ú˂̇ ‰Ë‡„ÌÓÒÚË͇, Á‡ ‰‡ Ò ̇χÎË ËÒÍ˙Ú ÓÚ ÔÓÒÚÓÔÂ‡ÚË‚ÌË ‰ÂÙˈËÚË. åçéÜÖëíÇÖçÄ ëìÅèàÄãçÄ íêÄçëÖäñàü åÌÓÊÂÒÚ‚Â̇ڇ ÒÛ·ÔˇÎ̇ Ú‡ÌÒÂ͈Ëfl (MST)  ÓÚÌÓÒËÚÂÎÌÓ ÌÓ‚‡ ԇΡÚ˂̇ ÓÔÂ‡Ú˂̇ ÚÂıÌË͇, ÍÓflÚÓ Ò ÔË·„‡ Á‡ ΘÂÌË ̇ ÂÔËÎÂÔÒËË Ò Ì‡˜‡ÎÓ Ì‡ ÔËÒÚ˙ÔËÚ ‚˙‚ ÙÛÌ͈ËÓ̇ÎÌÓ ÏÌÓ„Ó ‚‡Ê̇ ÏÓÁ˙˜Ì‡ ÍÓ‡, ̇Ô. Ú.̇. ◊ÍÓ„ÌËÚË‚ÌË ÂÔËÎÂÔÒËË” (23). óÂÁ ÒÔˆˇÎÂÌ ÌÓÊ Ò ÔÂÍ˙Ò‚‡Ú ڇ̄Â̈ˇÎÌËÚ ËÌÚ‡ÍÓÚË͇ÎÌË ‚·Í̇, ÌÂÓ·ıÓ‰ËÏË Á‡ ‡ÔÓÒÚ‡ÌÂÌËÂÚÓ Ì‡ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ‡ÍÚË‚ÌÓÒÚ, ͇ÚÓ Ì Ò ۂÂʉ‡Ú ‚ÂÚË͇ÎÌËÚ ‡ÙÂÂÌÚÌË Ë ÂÙÂÂÌÚÌË Ô˙Úˢ‡, ÌÂÓ·ıÓ‰ËÏË Á‡ ÓÒ˙˘ÂÒÚ‚fl‚‡ÌÂÚÓ Ì‡ ‚‡ÊÌË ÍÓÓ‚Ë ÙÛÌ͈ËË (23). Ç ÔÓÛ˜‚‡ÌËfl Ë ÏÂÚ‡-‡Ì‡ÎËÁË Â ÛÒÚ‡ÌÓ‚ÂÌÓ, ˜Â ·ÎËÁÓ 50% ÓÚ Ô‡ˆËÂÌÚËÚÂ Ò MST Ò‡ ·ËÎË ·ÂÁ ÔËÒÚ˙ÔË ÔÓÒÚÓÔÂ‡ÚË‚ÌÓ, ÓÍÓÎÓ 10% Ò‡ ËχÎË Ò‡ÏÓ 1-2 ÔËÒÚ˙Ô‡ „Ӊ˯ÌÓ, ÓÍÓÎÓ 20%, Ò˙ÓÚ‚ÂÚÌÓ, Ò‡ ·ËÎË Ò˙Ò Á̇˜ËÚÂÎÌÓ Ì‡Ï‡ÎÂÌË ̇ ÔËÒÚ˙Ô̇ڇ ˜ÂÒÚÓÚ‡ ËÎË ·ÂÁ ÂÙÂÍÚ (14,23,35). èË ÒË̉ÓÏ Ì‡ Landau-Kleffner MST, ÍÓÏ·ËÌË‡Ì‡ Ò ÂÁÂÍÚ˂̇ ÓÔÂ‡ˆËfl, ‚Ó‰Ë ‰Ó ӂ·‰fl‚‡Ì ̇ ÔËÒÚ˙ÔËÚ ÔË 75%, ‡ ‚ 44% Ò ÔÓÒÚË„‡ Ò˙ÓÚ‚ÂÚÌÓ Á‡ ‚˙Á‡ÒÚÚ‡ Â˜Â‚Ó ‡Á‚ËÚË (23). ìÒÎÓÊÌÂÌËflÚ‡ Ò‡ ÓÚÌÓÒËÚÂÎÌÓ ‰ÍË, ͇ÚÓ ÔÂıÓ‰ÌËÚ ҇ Ò ˜ÂÒÚÓÚ‡ ‰Ó ÓÍÓÎÓ 7% (23). ÇÄÉìë-çÖêÇ ëíàåìãÄñàü (VNS) èË̈ËÔ˙Ú Ì‡ ÒÚËÏÛ·ˆËflÚ‡ ̇ ÌÂ‚ÛÒ ‚‡„ÛÒ Í‡ÚÓ Ô‡ÎˇÚË‚ÌÓ Î˜ÂÌË ̇ ÂÔËÎÂÔÒËË Ò ÓÒÌÓ‚‡Ì‡ ̇ ÂÍÒÔÂËÏÂÌÚË ÔË ÊË‚ÓÚÌË, Í˙‰ÂÚÓ Â ÛÒÚ‡ÌÓ‚ÂÌÓ, ˜Â ÒÚËÏÛ·ˆËflÚ‡ ̇ ÚÓÁË ÌÂ‚ ̇χÎfl‚‡ ÂÔËÎÂÔÚ˘ÌËÚ ‡Áfl‰Ë.

58

ëÚËÏÛ·ÚÓ, ÔÓ‰Ó·ÂÌ Ì‡ Ò˙‰Â˜ÌËfl ÔÂÈÒÏÂÈÍ˙ Ë „ÂÌÂË‡˘ ÂÎÂÍÚ˘ÌË ËÏÔÛÎÒË, Ò ËÏÔ·ÌÚË‡ ÔÓ‰ ÍÓʇڇ ‚ ӷ·ÒÚÚ‡ ̇ Í·‚ËÍÛ·ڇ, ‡ ÔÓ‰‡‚‡˘ËflÚ ËÏÔÛÎÒË ÂÎÂÍÚÓ‰ Ò ÔÓÒÚ‡‚fl ‰ËÂÍÚÌÓ ‚˙ıÛ Î‚Ëfl ·ÎÛʉ‡Â˘ ÌÂ‚. VNS Ò ËÁÔÓÎÁ‚‡ Ô‰ËÏÌÓ, ‡ ̇ÔÓÒΉ˙Í ‚ ‡Á‚ËÚËÚ ÒÚ‡ÌË - Ò‡ÏÓ ÔË Ô‡ˆËÂÌÚË, ÍÓËÚÓ Ì ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÔÓ‰ÎÓÊÂÌË Ì‡ ÂÁÂÍÚ˂̇ ËÌÚÂ‚Â̈Ëfl Ë ÚÓ‚‡  ÛÒÚ‡ÌÓ‚ÂÌÓ ÒΉ ÔˆËÁÌË ËÁÒΉ‚‡ÌËfl. ÉÓÎÂÏË ÏÛÎÚˈÂÌÚÓ‚Ë ÔÓÛ˜‚‡ÌËfl ÔÓ͇Á‚‡Ú, ˜Â ÔË 37-43% ÓÚ Ô‡ˆËÂÌÚËÚ Ëχ ‰Û͈Ëfl ̇ ÔËÒÚ˙Ô̇ڇ ˜ÂÒÚÓÚ‡ ̇‰ 50% (4,6). VNS ËÁ„ÎÂʉ‡ ÂÙÂÍÚ˂̇ ÔË Ô‡ˆËÂÌÚË Ò Ô‰ıÓʉ‡˘‡ ͇ÎÓÁÓÚÓÏËfl. ìÒÎÓÊÌÂÌËflÚ‡ ÓÚ ËÏÔ·ÌÚË‡Ì VNS ‚Íβ˜‚‡Ú ̇Û¯ÂÌËfl ̇ „·҇, ˜ÂÒÚÓ Í‡¯ÎflÌÂ, Ô‡ÂÒÚÂÁËË, ‰ËÒÔÌÂfl, ‰ËÒÔÂÔÒËfl Ë Î‡ËÌ„ËÁ˙Ï (4,6). GAMMA KNIFE- à àçíÖêëíàñàÄãçÄ êÄÑàéïàêìêÉàü Ç ÔÓÒΉÌËÚ „Ó‰ËÌË ÒÚÂÂÓÚ‡ÍÚ˘̇ڇ ‡‰ËÓıËÛ„Ëfl Ò ÔË·„‡ Á‡ ΘÂÌË ̇ ωË͇ÏÂÌÚÓÁÌÓ-ÂÙ‡ÍÚÂÌË ÂÔËÎÂÔÒËË, ÓÒÓ·ÂÌÓ MTLE. íÛÍ Ò ÓÒ˙˘ÂÒÚ‚fl‚‡ ÙÓÍÛÒË‡ÌÓ Ì‡ÒÓ˜‚‡Ì ̇ ÓÔ‰ÂÎÂ̇ ‰ÓÁ‡ Î˙˜ÂÌË ‚˙ıÛ ÏÂÁˇÎÌËÚ ÒÚÛÍÚÛË. èË ÚÂÏÔÓ‡Î̇ ÂÔËÎÂÔÒËfl, ÎÂÍÛ‚‡Ì‡ Ò ‡‰ËÓıËÛ„Ëfl, ‚ÏÂÒÚÓ Ò˙Ò SAHE, Ò ÓÚ˜ËÚ‡ ÎËÔÒ‡ ̇ ÔËÒÚ˙ÔË ‚ 81% (27). ÇÂÓflÚÌÓ gamma knife ıËÛ„ËflÚ‡ Ë ‚ ·˙‰Â˘Â ˘Â Ëχ ÓÔ‰ÂÎÂ̇ ÓÎfl ‚ ΘÂÌËÂÚÓ Ì‡ MTLE, ÌÓ ÔËÎÓÊÂÌËÂÚÓ È ÔË ÂÍÒÚ‡ÚÂÏÔÓ‡ÎÌËÚ ÂÔËÎÂÔÒËË Â ÌÂflÒÌÓ. ÑÌÂÒ Ú‡ÁË ËÌÚÂ‚Â̈Ëfl Ëχ ÓÔ‰ÂÎÂÌÓ ÏflÒÚÓ ‚ ΘÂÌËÂÚÓ Ì‡ ıËÔÓڇ·Ï˘ÌË ı‡Ï‡ÚÓÏË Ò „·ÒÚ˘̇ ÂÔËÎÂÔÒËfl, Í˙‰ÂÚÓ ÔÓÒÚÓÔÂ‡ÚË‚ÌËÚ ÂÁÛÎÚ‡ÚË Ò ‰‡ÌÌË Á‡ 80% Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË Ò‡ ÏÌÓ„Óӷ¢‡‚‡˘Ë (27). ëÚÂÂÓÚ‡ÍÚ˘̇ڇ ËÏÔ·ÌÚ‡ˆËfl ̇ seed-ËÏÔ·ÌÚ‡ÚË (Ò˙‰˙ʇ˘Ë 125I) ÔË ÚÓÁË ‚ˉ ÂÔËÎÂÔÒËfl Ò˙˘Ó Ëχ ‰Ó·Ë ÂÁÛÎÚ‡ÚË ÔË ‰ÍË Ë ÌÂÁ̇˜ËÚÂÎÌË ÛÒÎÓÊÌÂÌËfl, ÌÓ ÂÁÛÎÚ‡ÚËÚ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÓÚ˜ÂÚÂÌË Â‰‚‡ ÒΉ ÌflÍÓÎÍÓ ÏÂÒˆ‡ (29). ÑÓ͇ÚÓ Ô‰ËÏÒÚ‚ÓÚÓ Ì‡ ‡‰ËÓıËÛ„ËflÚ‡ – ÎËÔÒ‡ ̇ Í‡ÌËÓÚÓÏËfl –  Ә‚ˉÌÓ, ÔÓ·ÎÂÏ˙Ú ÔË ÚÓÁË ‚ˉ ËÌÚÂ‚Â̈ËË Â, ˜Â ÔÓ‚ÎËfl‚‡ÌÂÚÓ Ì‡ ÔËÒÚ˙Ô̇ڇ ˜ÂÒÚÓÚ‡ Ò ̇·Î˛‰‡‚‡ ‰‚‡ ÒΉ ÏÂÒÂˆË ‰Ó ‰̇ „Ó‰Ë̇. áÄäãûóÖçàÖ ë˙‚ÂÏÂÌÌËÚ ÏÓ‰ÂÌË ÚÂıÌËÍË Ì‡ ËÁÒΉ‚‡Ì ÔÓÁ‚ÓÎfl‚‡Ú χÍÒËχÎÌÓ ÚÓ˜ÌÓ ‰‡ Ò ÓÔ‰ÂÎË ÏÓÁ˙˜ÌËfl ÒÛ·ÒÚ‡Ú, „ÂÌÂË‡˘ ÂÔËÎÂÔÚ˘ÌËÚ ÔËÒÚ˙ÔË. èË Ô‡ˆËÂÌÚË Ò Ú‡Í˙‚ ÛÒÔÂı Ë ÎËÔÒ‡ ̇ ÂÙÂÍÚ ÓÚ ÄÖå Úfl·‚‡ ‰‡ Ò ӷÒ˙ʉ‡ ÓÔÂ‡ÚË‚ÌÓ Î˜ÂÌËÂ. íÓ‚‡, ÍÓÂÚÓ ÔÓ-‡ÌÓ Â ·ËÎÓ ËÁÍβ˜ÂÌËÂ, ‰ÌÂÒ ÒÚ‡‚‡ ‚˜ ÛÚË̇ ‚ ÒÔˆˇÎËÁË‡ÌËÚ ÂÔËÎÂÔÚ˘ÌË ˆÂÌÚÓ‚Â. ÑÓ·ËÚ ÔÓÒÚÓÔÂ‡ÚË‚ÌË ÂÁÛÎÚ‡ÚË Ò˙Ò Ò‰̇ ÒÚÓÈÌÓÒÚ Á‡ Ò‚Ó·Ó‰‡ ÓÚ ÔËÒÚ˙ÔË ‰Ó 60-70% ÓÚ Ô‡ˆËÂÌÚËÚ (ÔË ÌflÍÓË ÓÔÂ‡ˆËË ‰Ó 90%) ÔÓ͇Á‚‡Ú, ˜Â ıËÛ„ËflÚ‡ ̇ ÂÔËÎÂÔÒËflÚ‡  ÏÌÓ„Ó ‚‡Ê̇ ÚÂ‡Ô‚Ú˘̇ ‚˙ÁÏÓÊÌÓÒÚ Á‡ ÂÙ‡ÍÚÂÌËÚ ÂÔËÎÂÔÒËË ‚˙‚ ‚Òfl͇ ‚˙Á‡ÒÚ. ãàíÖêÄíìêÄ 1. 2. 3. 4. 5. 6.

Binder, D.K., Schramm, J. Transsylvian functional hemispherectomy. Childs Nerv Syst 2006; 22: 960-6. Cascino, G.D., Sharbrough, F.W., Trenerry, M.R., et al. Extratemporal cortical resections and lesionectomies for partial epilepsy: complications of surgical treatment. Epilepsia 1994; 35: 1085-1090. Cendes, F., Ragazzo, P.C., da Costa, V. Corpus callosotomy in treatment of medically resistant pilepsy: preliminary results in a pediatric population. Epilepsia 1993; 34: 910-7. Chadwick, D. Vagal-nerve stimulation for epilepsy. Lancet 2001; 357: 17261727. Dalmagro, C.L., Bianchin, M.M., Velasco, T.R. Clinical features of patients with posterior cortex epilepsies and predictors of surgical outcome. Epilepsia 2005; 46: 1442-9. DeGiorgio, C.M., Schachter, S.C., Handforth, A., et al. Prospective long-term study of vagus nerve stimulation for the treatment of refractory seizures. Epilepsia 2000; 41:1195-1200.


‡ÔËÎ, 2007

7. 8. 9.

10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

Delalande, O., Pinard, J.M., Basdevant, C., et al. Hemispherotomy: a new procedure for central disconnection. Epilepsia 1992; 33S3: 99-100. Edwards, J.C., Wyllie, E., Ruggeri, P.M. Seizure outcome after surgery for epilepsy due to malformation of cortical development. Neurology 2000; 55: 1110-4 Engel, J., Wiebe, S., French, J. Practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the Quality Standards Subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurology. Neurology 2003; 60: 538-47 Fauser, S., Schulze-Bonhage, A., Honegger, J. Focal cortical dysplasias: surgical outcome in 67 patients in relation to histological subtypes and dual pathology. Brain 2004; 127: 2406-18 Foldvary, N., Nashold, B., Mascha, E. Seizure outcome after temporal lobectomy for temporal lobe epilepsy: a Kaplan-Meier survival analysis. Neurology 2000; 54: 630-4 Fountas, K.N., Smith, J.R., Robinson, J.S., Tamburrini, G., Pietrini, D., Di Rocco, C. Anatomical hemispherectomy. Childs Nerv Syst. 2006; 22: 982-91. Gonzalez-Martinez, J.A., Gupta, A., Kotagal, P. Hemispherectomy for catastrophic epilepsy in infants. Epilepsia 2005; 46: 1518-25. Grote, C., Van Slyke, P., Hoeppner, J. Language outcome following multiple subpial transection for Landau-Kleffner syndrome. Brain 1999; 122: 561-566. Janszky, J., Jokeit, H., Schulz, R. EEG predicts surgical outcome in lesional frontal lobe epilepsy. Neurology 2000; 54: 1470-6. Kim, D.W., Lee, S.K., Yun, C.H. Parietal lobe epilepsy: the semiology, yield of diagnostic workup, and surgical outcome. Epilepsia 2004; 45: 641-9. Kossoff, E.H., Vining, E.P., Pillas, D.J. Hemispherectomy for intractable unihemispheric epilepsy etiology vs outcome. Neurology 2003; 61: 887-90. Kral, T., Clusmann, H., Blumcke, I. Outcome of epilepsy surgery in focal cortical dysplasia. J Neurol Neurosurg Psychiatry 2003; 74: 183-8. Lee, S.K., Lee, S.Y., Kim, K.K. Surgical outcome and prognostic factors of cryptogenic neocortical epilepsy. Ann Neurol 2005; 58: 525-32. Li, L.M., Cendes, F., Andermann, F., et al. Surgical outcome in patients with epilepsy and dual pathology. Brain 1999; 122: 799-805. McInerney, J., Siegel, A.M., Nordgren, R.E., Ât al. Long-term seizure outcome following corpus callosotomy in children. Stereotact Funct Neurosurg 1999; 73: 79-83. McIntosh, A.M., Kalnins, R.M., Mitchell, L.A. Temporal lobectomy: longterm seizure outcome, late recurrence and risks for seizure recurrence. Brain 2004; 127: 2018-30. Morrel, F., Kanner, A.M., de Toledo-Morell, L., et al. Multiple subpial transection. Adv Neurol 1999; 81: 259-279. Mosewich, R.K., So, E.L., O'Brien, T.J. Factors predictive of the outcome of frontal lobe epilepsy surgery. Epilepsia 2000; 41: 843-9. O'Brien, D.F., Basu, S., Williams, D.H., May, P.L. Anatomical hemispherectomy for intractable seizures: excellent seizure control, low morbidity and no superficial cerebral haemosiderosis. Childs Nerv Syst 2006; 22: 489-498. Pre-surgical evaluation for epilepsy surgery - European standards. European Federation of Neurological Societies Task Force. Eur J Neurol 2000; 7: 119-22. Regis, J., Bartolomei, F., Hayashi, M., et al. The role of gamma knife surgery in the treatment of severe epilepsies. Epileptic Disorders 2000; 2: 113-122.

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28. Salanova, V., Markand, O., Worth, R. Temporal lobe epilepsy surgery: outcome, complications, and late mortality rate in 215 patients. Epilepsia 2002; 43: 170-4. 29. Schulze-Bonhage, A., Homberg, V., Trippel, M., et al. Interstitial radiosurgery in the treatment of gelastic epilepsy due to hypothalamic hamartomas. Neurology 2004; 62: 644-7. 30. Siegel, A.M., Cascino, G.D., Meyer, F.B. Surgical outcome and predictive factors in adult patients with intractable epilepsy and focal cortical dysplasia. Acta Neurol Scand 2006; 113: 65-71. 31. Siegel, A.M., Jobst, B.C., Thadani, V.M., et al. Medically intractable, localization-related epilepsy with normal MRI: presurgical evaluation and surgical outcome in 43 patients. Epilepsia 2001; 42: 883-888. 32. Sisodiya, S.M. Surgery for malformations of cortical development causing epilepsy. Brain 2000; 123: 1075-91. 33. Spencer, S.S., Berg, A.T., Vickrey, B.G. Initial outcomes in the Multicenter Study of Epilepsy Surgery. Neurology 2003; 61: 1680-5. 34. Spencer, S.S., Berg, A.T., Vickrey, B.G. Predicting long-term seizure outcome after resective epilepsy surgery: the multicenter study. Neurology 2005; 65: 912-8. 35. Spencer, S.S., Schramm, J., Wyler, A., et al. Multiple subpial transection for intractable partial epilepsy: An international meta-analysis. Epilepsia 2002; 43:141-145. 36. Terra-Bustamante, V.C., Inuzuka, L.M., Fernandes, R.M., et al. Outcome of hemispheric surgeries for refractory epilepsy in pediatric patients. Childs Nerv Syst. 2007; 23:321-6. 37. Turanli, G., Yalnizoglu, D., Genc-Acikgoz, D., Akalan, N., Topcu, M. Outcome and long term follow-up after corpus callosotomy in childhood onset intractable epilepsy. Childs Nerv Syst 2006; 22: 1322-7. 38. Villemure, J.G., Daniel, R.T. Peri-insular hemispherotomy in paediatric epilepsy. Childs Nerv Syst 2006; 22: 967-81. 39. Wieser, H.G., Blume, W.T., Fish, D. ILAE Commission Report. Proposal for a new classification of outcome with respect to epileptic seizures following epilepsy surgery. Epilepsia 2001; 42: 282-6. 40. Wieser, H.G., Siegel, A.M. Analysis of Foramen ovale electrodes recorded seizures: correlation with outcome following amygdalohippocampectomy. Epilepsia 1991; 32: 838-850. 41. Wieser, H.G., Yasargil, M.G. Selective amygdalohippocampectomy as a surgical treatment of mesiobasal limbic epilepsy. Surg Neurol 1982; 17: 445-457.

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: Ñ- èÂÚfl ëÚ. ÑËÏÓ‚‡, ‰Ï ÑÂÚÒ͇ Ì‚ÓÎӄ˘̇ ÍÎËÌË͇, ìë ÅÄãçè“ë‚.ç‡ÛÏ” – IV ÍÏ. ìÎ. “Ñ- ã. êÛÒ‚” ‹1 1113 ëÓÙËfl íÂÎ: 9702 – 232 Ö-mail: pdimova@cablebg.net

é·ÁÓ ïàêìêÉàü çÄ ÖèàãÖèëàüíÄ - èêÖïàêìêÉàóçÄ ÑàÄÉçéëíàäÄ (II) èÂÚfl ÑËÏÓ‚‡ ÑÂÚÒ͇ Ì‚ÓÎӄ˘̇ ÍÎËÌË͇, ìëÅÄãçè “ë‚.ç‡ÛÏ” – ëÓÙËfl

SUMMARY EPILEPSY SURGERY - PRESURGICAL EVALUATION (II) Petia Dimova About 1/4 of patients with refractory focal epilepsy can be cured by a surgical intervention removing the brain area where the seizures are originating (epileptogenic zone). Potential candidates have to undergo an extensive presurgical work-up. During the non-invasive phase a long-term videoEEG monitoring, a high resolution MRI, a SPECT and/or PET, a neuropsychological evaluation and other neurophysiological examinations should be performed. If the epileptogenic zone cannot be localized adequately with these methods, invasive electrophysiological techniques have to be applied. After interdisciplinary discussion of the results of all examinations and assessment of the surgical approach and potential risks, the actual epileptic surgery could be performed. As a result of precise presurgical evaluation, up to 6080% patients can be rendered seizure free without substantial

postoperative sequelae. Hence, the epilepsy surgery can be regarded as an effective treatment option for patients with medically refractory localization-related epilepsies. KEY WORDS: epilepsy, EEG, diagnostics, presurgical, surgery. êÖáûåÖ éÍÓÎÓ 1/4 ÓÚ Ô‡ˆËÂÌÚËÚÂ Ò ÂÁËÒÚÂÌÚÌË ÙÓ͇ÎÌË ÂÔËÎÂÔÒËË ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÎÂÍÛ‚‡ÌË ˜ÂÁ ıËÛ„˘ÌÓ ÓÚÒÚ‡Ìfl‚‡Ì ̇ ÏÓÁ˙˜Ì‡Ú‡ ӷ·ÒÚ, „ÂÌÂË‡˘‡ ÂÔËÎÂÔÚ˘ÌËÚ ÔËÒÚ˙ÔË (ÂÔËÎÂÔÚÓ„ÂÌ̇ ÁÓ̇). èÓÚÂ̈ˇÎÌËÚ ͇̉ˉ‡ÚË ÒΉ‚‡ ‰‡ ÔÂÏËÌ‡Ú Ó·¯Ë̇ ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚË͇. èÓ ‚ÂÏ ̇ ÌÂËÌ‚‡Á˂̇ڇ Ù‡Á‡ Ò ÔÓ‚Âʉ‡ ËÌÚÂÌÁË‚ÌÓ ‚ˉÂÓ-ÖÖÉ ÏÓÌËÚÓË‡ÌÂ, ‚ËÒÓÍÓ‡Á‰ÂÎËÚÂÎ̇ åêí, SPECT Ë/ËÎË PET, Ì‚ÓÔÒËıÓÎӄ˘̇ ÓˆÂÌ͇ Ë ‰Û„Ë Ì‚ÓÙËÁËÓÎӄ˘ÌË ËÁÒΉ‚‡ÌËfl. ÄÍÓ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇ Ì ÏÓÊ ‰‡ ·˙‰Â ÎÓ͇ÎËÁË‡Ì‡ ‡‰ÂÍ‚‡ÚÌÓ Ò ÚÂÁË ÏÂÚÓ‰Ë, Ò ÔÂÏË̇‚‡ Í˙Ï ËÌ‚‡ÁË‚ÌË ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ÚÂıÌËÍË. ëΉ ËÌÚÂ‰ËÒˆËÔÎË̇-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÌÓ Ó·Ò˙ʉ‡Ì ̇ ÂÁÛÎÚ‡ÚËÚ ÓÚ ‚Ò˘ÍË ËÁÒΉ‚‡ÌËfl Ë ÔˆÂÌ͇ ̇ Ò˙ÓÚ‚ÂÚÌËfl ÓÔÂ‡ÚË‚ÂÌ ÔÓ‰ıÓ‰ Ë ‚˙ÁÏÓÊÌËÚ ËÒÍÓ‚Â Ò ÔÂÏË̇‚‡ Í˙Ï ‰ÂÈÒÚ‚ËÚÂÎ̇ڇ ıËÛ„Ëfl ̇ ÂÔËÎÂÔÒËflÚ‡. èË Ï‡ÍÒËχÎÌÓ ÔˆËÁ̇ ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚË͇ ‰Ó 60-80% ÓÚ Ô‡ˆËÂÌÚËÚ ÏÓ„‡Ú ‰‡ Ò‡ Ò‚Ó·Ó‰ÌË ÓÚ ÔËÒÚ˙ÔË, ·ÂÁ Á̇˜ËÏË Ì„‡ÚË‚ÌË ÔÓÒΉÒÚ‚Ëfl. íÓ‚‡ Ô‡‚Ë ÂÔËÎÂÔÚ˘̇ڇ ıËÛ„Ëfl ÂÙÂÍÚ˂̇ ÚÂ‡Ô‚Ú˘̇ ‚˙ÁÏÓÊÌÓÒÚ ÔË Ô‡ˆËÂÌÚË Ò Ï‰Ë͇ÏÂÌÚÓÁÌÓ-ÂÁËÒÚÂÌÚÌË ÎÓ͇ÎËÁ‡ˆËÓÌÌÓ-Ò‚˙Á‡ÌË ÂÔËÎÂÔÒËË. äãûóéÇà Ñìåà: ÂÔËÎÂÔÒËfl, ıËÛ„Ëfl, ÔÂıËÛ„˘̇, ‰Ë‡„ÌÓÒÚË͇, ÖÖÉ. ÇöÇÖÑÖçàÖ ÖÔËÎÂÔÚ˘̇ڇ ıËÛ„Ëfl Ò ËÁ‚˙¯‚‡ Ò ˆÂΠӂ·‰fl‚‡Ì ̇ ÂÔËÎÂÔÚ˘ÌËÚ ÔËÒÚ˙ÔË, ËÁ·fl„‚‡Ì ̇ ÒÚ‡Ì˘ÌËÚ ÂÙÂÍÚË Ì‡ ‡ÌÚËÂÔËÎÂÔÚ˘ÌËڠωË͇ÏÂÌÚË (ÄÖå) Ë ÓÔÚËχÎÌÓ Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ Ì‡ Ô‡ˆËÂÌÚ‡. ë˙˘ÂÒÚ‚ÂÌÓ ÔÂËÏÛ˘ÂÒÚ‚Ó Á‡ Á‰‡‚̇ڇ ÒËÒÚÂχ Ë Ó·˘ÂÒÚ‚ÓÚÓ Â Á̇˜ËÚÂÎÌÓÚÓ Ì‡Ï‡Îfl‚‡Ì ̇ ‰ËÂÍÚÌËÚÂ Ë Ë̉ËÂÍÚÌË Ï‰ˈËÌÒÍË ‡ÁıÓ‰Ë Á‡ Ô‡ˆËÂÌÚËÚÂ Ò ‰˙΄ӄӉ˯ÌË ÂÙ‡ÍÚÂÌË ÂÔËÎÂÔÒËË (5,13,14). í˙È Í‡ÚÓ ˆÂÎÚ‡ ̇ ÂÁÂÍÚ˂̇ڇ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl  ÓÚÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ Ô˙‚˘̇ڇ ÂÔËÎÂÔÚÓ„ÂÌ̇ ÁÓ̇ (ÁÓ̇ڇ, ÌÂÓ·ıÓ‰Ëχ Á‡ „ÂÌÂË‡Ì ̇ ÍÎËÌ˘ÌËÚ ÔËÒÚ˙ÔË),  ÌÂÓ·ıÓ‰ËÏÓ Úfl ‰‡ Ò ˉÂÌÚËÙˈË‡ χÍÒËχÎÌÓ ÚÓ˜ÌÓ (1,2,10,11,16,20,26,34). ÄÍÓ ÚÓ‚‡ Ì  ‚˙ÁÏÓÊÌÓ, Ò ÔÂÏË̇‚‡ Í˙Ï ‡ÎÚÂ̇ÚË‚ÌË, ԇΡÚË‚ÌË ıËÛ„˘ÌË Ôӈ‰ÛË (͇ÎÓÁÓÚÓÏËfl, ÏÌÓÊÂÒÚ‚Â̇ ÒÛ·ÔˇÎ̇ Ú‡ÌÒÂ͈Ëfl, VNS ËÏÔ·ÌÚ‡ˆËfl (16). à ‰‚‡Ú‡ ‚ˉ‡ ıËÛ„˘ÌÓ Î˜ÂÌË Ò ËÁ‚˙¯‚‡ ÔË ÎÓ͇ÎËÁ‡ˆËÓÌÌÓ-Ò‚˙Á‡ÌË ÂÔËÎÂÔÒËË, ÍÓËÚÓ Ì Ò ‚ÎËflflÚ ‡‰ÂÍ‚‡ÚÌÓ ÓÚ ÄÖå (ÎËÔÒ‡ ̇ ÍÓÌÚÓÎ ËÎË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË). Ç˙ÔÂÍË ˜Â ‰Ó͇Á‚‡ÌÂÚÓ Ì‡ ωË͇ÏÂÌÚÓÁ̇ ÂÁËÒÚÂÌÚÌÓÒÚ Ì ËÁ„ÎÂʉ‡ ÚÛ‰ÂÌ ÔÓˆÂÒ, ‚Ò Ӣ ÏÌÓ„Ó ◊͇̉ˉ‡ÚË” ·Ë‚‡Ú ̇ÒÓ˜‚‡ÌË Ú‚˙‰Â Í˙ÒÌÓ, ÍÓÂÚÓ Ëχ Á̇˜ËÚÂÎÌË ÔÓÒÎÂ‰ËˆË Á‡ Ô‡ˆËÂÌÚ‡, Ì„ӂÓÚÓ ÒÂÏÂÈÒÚ‚Ó Ë Ó·˘ÂÒÚ‚ÓÚÓ (3,5,8,9,12,13,14,27,28). èÓ‡‰Ë ÚÓ‚‡, ‚ Ò˙‚ÂÏÂÌ̇ڇ ÂÔËÎÂÔÚÓÎÓ„Ëfl ıËÛ„˘ÌÓÚÓ Î˜ÂÌË ‚˜ Ì Ò ‡Á„ÎÂʉ‡ ͇ÚÓ ÚÂ‡ÔËfl ̇ ÔÓÒΉÂÌ ËÁ·Ó. Ç ÒÔˆˇÎËÁË‡ÌË ÂÔËÎÂÔÚ˘ÌË ˆÂÌÚÓ‚Â Ò ËÁ‚˙¯‚‡Ú ÔˆËÁÌË Ì‚ÓËÁÓ·‡Áfl‚‡˘Ë Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ËÁÒΉ‚‡ÌËfl, ÔÓÁ‚ÓÎfl‚‡˘Ë ÓÔÂ‡ÚË‚ÌË ÔÓ‰ıÓ‰Ë ‚ ‡Ì̇ ‰ÂÚÒ͇ Ë ‰ÓË Í˙χ˜ÂÒ͇ ‚˙Á‡ÒÚ. Ç ‡Á‚ËÚËÚ ÒÚ‡ÌË Ì‡ Ö‚ÓÔ‡ Ë ÄÏÂË͇ Ò‡ ‡Á‡·ÓÚÂÌË Òڇ̉‡ÚË Á‡ ÒÂÎÂ͈Ëfl Ë ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚË͇ ̇ ͇̉ˉ‡ÚËÚ Á‡ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl, ÍÓËÚÓ Ò ÓÒÌÓ‚‡‚‡Ú ̇ ÒÚÓ„Ë ÍËÚÂËË Ë Ô‡‚Ë· Á‡ ‡·ÓÚ‡ (1,3,8,12,13,16,22,25). àÁ‚˙¯‚‡ Ò ‚ÌËχÚÂÎÌÓ ËÌÚÂ‰ËÒˆËÔÎË̇ÌÓ Ó·Ò˙ʉ‡Ì ̇ ÂÁÛÎÚ‡ÚËÚ ÓÚ Ôӂ‰ÂÌËÚ ËÁÒΉ‚‡ÌËfl, ‚˙ÁÏÓÊÌËÚ ÓÔÂ‡ÚË‚ÌË ÚÂıÌËÍË Ë ËÒÍÓ‚ÂÚ ÓÚ ıËÛ„˘ÌÓÚÓ Î˜ÂÌËÂ, ÔÂËÓ‰‡ Ë Ì‡˜Ë̇ ̇ ÔÓÒΉfl‚‡Ì ̇ Ô‡ˆËÂÌÚËÚ (1,5,7,8,15,16,22). ÖíÄèà çÄ ÖèàãÖèíàóçÄíÄ ïàêìêÉàü ÖÔËÎÂÔÚ˘̇ڇ ıËÛ„Ëfl ÏË̇‚‡ ÔÂÁ ÌflÍÓÎÍÓ Á‡‰˙ÎÊËÚÂÎÌË ÂÚ‡Ô‡: ËÁ·Ó ̇ ͇̉ˉ‡ÚË, ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚË͇ (ËÌ‚‡Á˂̇ Ë ÌÂËÌ‚‡Á˂̇, ıËÛ„Ëfl per se Ë ÔÓÒÚıËÛ„˘ÌÓ ÔÓÒΉfl‚‡ÌÂ) (1,16,22). çÂÓ·ıÓ‰ËÏÓ Â ‰‡ Ò‡ ̇Îˈ ÒΉÌËÚ ÚË ÛÒÎÓ‚Ëfl Á‡ ÔÓÒÚ‡‚flÌÂÚÓ Ì‡ Ë̉Ë͇ˆËflÚ‡ ıËÛ„˘ÌÓ Î˜ÂÌË ̇ ÂÔËÎÂÔÒËflÚ‡ (16): 1. èÓÚ‚˙ʉ‡‚‡Ì ̇ ‰Ë‡„ÌÓÁ‡Ú‡ Ë ‰Ó͇Á‚‡Ì ̇ ÚÂ‡Ô‚Ú˘̇ڇ ÂÁËÒÚÂÌÚÌÓÒÚ (ËÁ‚˙¯‚‡ Ò ÓÚ Ì‚ÓÎÓ„ ËÎË Ì‚ÓÔ‰ˇÚ˙). éÒÌÓ‚‡‚‡Ú Ò ̇ ÍÎËÌ˘ÌËÚ ‰‡ÌÌË Ë Ì‡ıÓ‰ÍËÚ ÓÚ Ì‚ÓËÁÓ·‡Áfl‚‡˘ËÚ ËÁÒΉ‚‡ÌËfl (Á‡‰˙ÎÊËÚÂÎÌÓ Ï‡„ÌËÚÌÓ-ÂÁÓ̇ÌÒ̇ ÚÓÏÓ„‡ÙËfl – åêí). ᇠ‰Ó͇Á‚‡Ì ̇ ωË-

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͇ÏÂÌÚÓÁ̇ ÂÁËÒÚÂÌÚÌÓÒÚ ËÎË ÌÂÔÓÌÓÒËÏÓÒÚ Ò ËÁËÒÍ‚‡ ÔËÎÓÊÂÌË ̇ ÔÓÌ 2 Ò˙ÓÚ‚ÂÚÌË Á‡ ‚ˉ‡ ̇ ÂÔËÎÂÔÒËflÚ‡ ÄÖå ͇ÚÓ Ò‰ÒÚ‚‡ ̇ Ô˙‚Ë ËÁ·Ó Ë ÔÓÌ ‰̇ ÍÓÏ·ËÌË‡Ì‡ ÚÂ‡ÔËfl. 2. çÂÓ·ıÓ‰Ëχ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ. èË ‚˙Á‡ÒÚÌË Úfl ÒΉ‚‡ ‰‡ ·˙‰Â Ì ÔÓ-χÎ͇ ÓÚ 2 „Ó‰ËÌË, ‰Ó͇ÚÓ ÔË ‰Âˆ‡ ÔÂËÓ‰˙Ú ÏÓÊ ‰‡  ÔÓÍ˙Ò. èË ÊË‚ÓÚÓÁ‡ÒÚ‡¯‡‚‡˘Ë Ò˙ÒÚÓflÌËfl Úfl·‚‡ ‰‡ ·˙‰Â ‰Ó͇Á‡Ì‡ Ì‚˙ÁÏÓÊÌÓÒÚÚ‡ Á‡ ΘËÏÓÒÚ. 3. Ç˙Á‡ÒÚÓ‚Ë „‡ÌˈË. é·ËÍÌÓ‚ÂÌÓ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl Ò ËÁ‚˙¯‚‡ ‚˙‚ ‚˙Á‡ÒÚÚ‡ ÏÂÊ‰Û 1 Ë 60 „. ◊ä·Ò˘ÂÒÍËÚ” ÍËÚÂËË Á‡ ËÁ·Ó ̇ ıËÛ„˘ÌË Í‡Ì‰Ë‰‡ÚË Ì‡ Walker ÓÚ 1974 „. ‚‡Ê‡Ú Ë ‰Ó ‰ÌÂÒ, ͇ÚÓ ÏÓ‰ËÙË͇ˆËË Ò‡ ‚˙ÁÏÓÊÌË ‚ ÚË ÒÎÛ˜‡fl: 1) ÌÂÓ·ıÓ‰ËÏÓÒÚ ÓÚ ‡Ì̇ ıËÛ„Ëfl ÔË ÌflÍÓË ÂÔËÎÂÔÚ˘ÌË ÒË̉ÓÏË (̇Ô. ÚÂÏÔÓ‡Î̇ڇ ÂÔËÎÂÔÒËfl ÔË ÏÂÁˇÎ̇ ÒÍÎÂÓÁ‡ = MTLE); 2) ◊ԇΡÚ˂̇” ıËÛ„Ëfl Ë 3) ÎË·Â‡Î̇ Ë̉Ë͇ˆËfl ‚ ‰ÂÚÒ͇ ‚˙Á‡ÒÚ, ÓÒÓ·ÂÌÓ ÔË Í‡Ú‡ÒÚÓÙ‡ÎÌË ÂÔËÎÂÔÒËË (16). èêàçñàèà çÄ èêÖïàêìêÉàóçÄíÄ ÑàÄÉçéëíàäÄ ä‡Ì‰Ë‰‡ÚËÚ Á‡ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl Ò ̇ÒÓ˜‚‡Ú Í˙Ï ÒÔˆˇÎËÁË‡ÌË ÂÔËÎÂÔÚ˘ÌË ˆÂÌÚÓ‚Â (8,16,22). ëÔÓ‰ Ò˙‚ÂÏÂÌ̇ڇ ÙÛ̉‡ÏÂÌÚ‡Î̇ ÍÓ̈ÂÔˆËfl Á‡ ÂÔËÎÂÔÚ˘̇ ıËÛ„Ëfl, ÔÂıËÛ„˘̇ڇ ‰Ë‡„ÌÓÒÚË͇  ̇ÒÓ˜Â̇ Í˙Ï Ë‰ÂÌÚËÙˈË‡Ì ̇ ÌflÍÓÎÍÓ ‚‡ÊÌË ÍÓÓ‚Ë ÁÓÌË, Û˜‡ÒÚ‚‡˘Ë ‚ ı‡‡ÍÚÂËÒÚË͇ڇ ̇ ÂÔËÎÂÔÒËflÚ‡: ÒËÏÔÚÓχÚÓ„ÂÌ̇ ÁÓ̇, ËËÚ‡Ú˂̇ ÁÓ̇, ÁÓ̇ ̇ ̇˜‡ÎÓ Ì‡ ÔËÒÚ˙ÔËÚÂ, ÁÓ̇ ̇ ÙÛÌ͈ËÓ̇ÎÂÌ ‰ÂÙˈËÚ Ë ÂÔËÎÂÔÚÓ„ÂÌ̇ ÎÂÁËfl, ÍÓËÚÓ Ôӂ˜ ËÎË ÔÓ-χÎÍÓ ÓÔ‰ÂÎflÚ ÎÓ͇ÎËÁ‡ˆËflÚ‡ Ë ‡ÁÏÂ‡ ̇ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇ (26). ᇠ‰‡ Ò ‰ÓÒÚË„Ì ‰Ó ÌÂÈÌÓÚÓ Ï‡ÍÒËχÎÌÓ ÚÓ˜ÌÓ ı‡‡ÍÚÂËÁË‡Ì Ò ÏË̇‚‡ ÔÂÁ ÌflÍÓÎÍÓ ÂÚ‡Ô‡ (3,16, 20,26, 34): 1. å‡ÍÒËχÎÌÓ ÚӘ̇ ‰Ë‡„ÌÓÁ‡ Ò Í·ÒËÙË͇ˆËfl ̇ ÂÔËÎÂÔÒËflÚ‡. éÒÌÓ‚‡‚‡ Ò ̇ Ô˙Î̇ Ë ÔÓ‰ӷ̇ ωˈËÌÒ͇ ‡Ì‡ÏÌÂÁ‡. àÁÍβ˜‚‡ÌÂÚÓ Ì‡ ÔÓ„ÂÒË‚ÌË Á‡·ÓÎfl‚‡ÌËfl, ÓÒÓ·ÂÌÓ ‚ ‰ÂÚÒ͇ڇ ‚˙Á‡ÒÚ, Í˙‰ÂÚÓ Ì‚ÓÏÂÚ‡·ÓÎËÚÌËÚ ‰Â„ÂÌÂ‡ÚË‚ÌË ·ÓÎÂÒÚË Ò‡ ˜ÂÒÚË Ë ÔÓÚ˘‡Ú Ò ÂÁËÒÚÂÌÚÌË ÔÓÎËÏÓÙÌË ÂÔËÎÂÔÚ˘ÌË ÔËÒÚ˙ÔË, ÔÓÌflÍÓ„‡ Ò˙˘Ó ÒÚ‡‚‡ ‰‚‡ ‚ ÒÔˆˇÎËÁË‡ÌËÚ ÂÔËÎÂÔÚ˘ÌË ˆÂÌÚÓ‚Â. ê‰ÍË Ë‰ËÓÔ‡Ú˘ÌË ÙÓÏË Ì‡ ÙÓ͇Î̇ ÂÔËÎÂÔÒËfl Ò Ì‡˜‡ÎÓ ‚˙‚ ‚Òfl͇ ‚˙Á‡ÒÚ, ÍÓËÚÓ a priori Ì ҇ ÔÓ‰ıÓ‰fl˘Ë Á‡ ıËÛ„˘ÌÓ Î˜ÂÌË ÔÓ‡‰Ë „ÂÌÂÚ˘̇ڇ ÓÒÌÓ‚‡ ̇ ÂÔËÎÂÔÚÓ„ÂÌÂÁ‡Ú‡ (̇Ô. Ù‡ÏËÎÌËÚ ÂÔËÎÂÔÒËË ÓÚ ÙÓÌÚ‡ÎÌËfl ‰flÎ, Ù‡ÏËÎ̇ڇ ÂÔËÎÂÔÒËfl Ò ÔÓÏÂÌÎË‚Ë Ó„Ìˢ‡, ‡ÚËÔ˘ÌË ÙÓÏË Ì‡ ˉËÓÔ‡Ú˘ÌË ‰ÂÚÒÍË ÙÓ͇ÎÌË ÂÔËÎÂÔÒËË), ÏÓ„‡Ú ‰‡ ÔÓÚ˘‡Ú Ò ÚÂ‡Ô‚Ú˘̇ ÂÁËÒÚÂÌÚÌÓÒÚ Ë Úflı̇ڇ ÚӘ̇ ÌÓÁÓÎӄ˘̇ ÔË̇‰ÎÂÊÌÓÒÚ ÔÓÌflÍÓ„‡ Ò˙˘Ó ·Ë‚‡ ÚÓ˜ÌÓ ÓÔ‰ÂÎÂ̇ ‰‚‡ ÔË Ó·Ò˙ʉ‡Ì Á‡ ıËÛ„˘ÌÓ Î˜ÂÌËÂ. éÚ „ÓÎflÏÓ Á̇˜ÂÌË Á‡ ˉÂÌÚËÙˈË‡ÌÂÚÓ Ì‡ ÒËÏÔÚÓχÚÓ„ÂÌ̇ڇ ÁÓ̇  ÔÓÁ̇‚‡ÌÂÚÓ Ì‡ ËÍÚ‡ÎÌË Ë ÔÓÒÚËÍÚ‡ÎÌË ÒËÏÔÚÓÏË, ÍÓËÚÓ ËÏ‡Ú Î‡ÚÂ‡ÎËÁË‡˘Ó Á̇˜ÂÌËÂ, Ë ÒËÏÔÚÓÏË ËÎË Â‚ÓβˆËfl ̇ ÒËÏÔÚÓÏË Ò ÎÓ͇ÎËÁË‡˘Ó Á̇˜ÂÌË (̇Ô. ‡Û‡, ÒÂÏËÓÎÓ„Ëfl ̇ ‰ÓÏËÌË‡˘ËÚ ÔËÒÚ˙ÔË) (4,26). 2. éÔ‰ÂÎflÌ ̇ ‚ˉ‡, ‡Ì‡ÚÓÏ˘̇ڇ ÎÓ͇ÎËÁ‡ˆËfl Ë ‡ÁÏÂ‡ ̇ ÏÓÙÓÎӄ˘̇ڇ ÒÚÛÍÚÛ̇ ÎÂÁËfl. è‰ÔÓ˜Ëڇ̇ ÏÓ‰‡ÎÌÓÒÚ Ò‰ Ì‚ÓËÁÓ·‡Áfl‚‡˘ËÚ ÏÂÚÓ‰ËÍË Ëχ ‚ËÒÓÍÓ‡Á‰ÂÎËÚÂÎ̇ڇ åêí (ÒÂÁÓ‚Â 1 Ë 2 ÏÏ), ͇ÚÓ ËÁÒΉ‚‡ÌÂÚÓ Ò ËÁ‚˙¯‚‡ ‚ ÌflÍÓÎÍÓ ÒÂÍ‚Â̈ËË (Á‡‰˙ÎÊËÚÂÎÌÓ í1, í2, FLAIR) Ë ‚Ò˘ÍË ‡‚ÌËÌË (Ò‡„ËÚ‡Î̇, ‡ÍÒˇÎ̇, ÍÓÓ̇̇). è‰ËÏÒÚ‚Ó Â Ì‡Î˘ËÂÚÓ Ì‡ 3í high-field MêT Ò „Ó-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÎflÏ ÍÓÌÚ‡ÒÚ Ì‡ ËÁÓ·‡ÊÂÌËÂÚÓ Ë ÏÌÓ„Ó ‚ËÒÓ͇ ‡Á‰ÂÎËÚÂÎ̇ ÒÔÓÒÓ·ÌÓÒÚ, ÔÓ‡‰Ë ÍÓÂÚÓ ÔÓ̇ÒÚÓfl˘ÂÏ Úfl  Á‡‰˙ÎÊËÚÂÎÂÌ ÂÍ‚ËÁËÚ ‚ „ÓÎÂÏËÚ ÂÔËÎÂÔÚ˘ÌË ˆÂÌÚÓ‚Â (16,21,32,33). ÇÒÂÍË ÂÔËÎÂÔÚ˘ÂÌ ˆÂÌÚ˙ Ëχ ÔÓÚÓÍÓÎ Á‡ ÔÓ‚Âʉ‡Ì ̇ ÔÂıËÛ„˘̇ åêí ‰Ë‡„ÌÓÒÚË͇. ᇠÔËÏÂ  ÔÓÒÓ˜ÂÌ ÔÓÚÓÍÓÎ˙Ú, ‚ÍÎ. ‰Â·ÂÎË̇ ̇ ÒÂÁÓ‚ÂÚ Á‡ 1,5 í åêí ‡Ô‡‡Ú, ̇ ‰ËÌ ÓÚ ‚Ӊ¢ËÚ ÂÔËÎÂÔÚ˘ÌË ˆÂÌÚÓ‚Â ‚ Ö‚ÓÔ‡ – ÔË ·ÓÎÌˈ‡ Niguarda, Claudio Munari Epilepsy Center, åË·ÌÓ (6,30,31) ● ÄÍÒˇÎÌÓ (Ú‡ÌÒ‚ÂÁ‡ÎÌÓ) ËÁÏÂ‚‡Ì (spin echo) SE DR-T2WI - 4-6 ÏÏ ● äÓÓ̇ÌÓ ËÁÏÂ‚‡Ì (turbo spin echo) TSE-T2WI - 3 ÏÏ ● äÓÓ̇ÌÓ ËÁÏÂ‚‡Ì (turbo spin echo inversion recovery) TSE IR-T1WI - 3 ÏÏ ● äÓÓ̇ÌÓ Ë Ò‡„ËÚ‡ÎÌÓ (fluid-attenuated inversion recovery) TSE-FLAIR T2WI - 3 ÏÏ ● 뇄ËÚ‡ÎÌÓ ËÎË ÍÓÓ̇ÌÓ ËÁÏÂ‚‡Ì (3D volume fast field echo) 3D FFE-T1WI - 1 ÏÏ ● + ‡ÍÒˇÎÌÓ/ÍÓÓ̇ÌÓ SE-T1WI Ò ÍÓÌÚ‡ÒÚ GdDTPA: ÔË Ò˙ÏÌÂÌË Á‡ ̇Û¯Â̇ Í˙‚ÌÓ-ÏÓÁ˙˜Ì‡ ·‡ËÂ‡. ÑÓÔ˙ÎÌËÚÂÎÌÓ Ò ÔË·„‡ Ú.̇. postprocessing ̇ åêí ÂÁÛÎÚ‡ÚËÚÂ, ÔË ÍÓÈÚÓ ˜ÂÁ ÍÓÏÔ˛Ú˙̇ Ó·‡·ÓÚ͇ ̇ ‰‡ÌÌËÚ ÓÚ åêí (Ó·ËÍÌÓ‚ÂÌÓ ÔÓÎÛ˜ÂÌË ÔË ËÁÒΉ‚‡Ì ‚ í1-ËÁÏÂ‚‡ÌÂ Ë ÔË ÒÂÁÓ‚Â 1 ÏÏ ‚˙‚ ‚Ò˘ÍË ‡‚ÌËÌË) Ò ‰Ó·Ë‚‡ ̇˜‡ÎÂÌ ÚËËÁÏÂÂÌ Ó·‡Á ̇ ÏÓÁ˙͇, Ò ‚˙ÁÏÓÊÌÓÒÚ Á‡ ÔÓÒΉ‚‡˘Ó ‚ËÁÛ‡ÎËÁË‡Ì ̇ ‰ÂÚ‡ÈÎË ÓÚ ‡Ì‡ÚÓÏ˘̇ ÎÂÁËfl, Ò ÓÚ΢ÂÌ ÍÓÌÚ‡ÒÚ ÏÂÊ‰Û ÒË‚ÓÚÓ Ë ·flÎÓ ÏÓÁ˙˜ÌÓ ‚¢ÂÒÚ‚Ó Ë Ï‡ÍÒËχÎÌÓ ÚÓ˜ÌÓ ÓÔ‰ÂÎflÌ ‡ÁÏÂ‡ ̇ ÎÂÁËflÚ‡ (18). í‡Í‡ ÒÚ‡‚‡ ‚˙ÁÏÓÊÌÓ ÓÔ‰ÂÎflÌÂÚÓ Ì‡ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÎÂÁËfl, ÍÓÂÚÓ ‚ Ì χÎÍÓ ÒÎÛ˜‡Ë  ÚÛ‰ÌÓ, ÔÓ‡‰Ë ÎËÔÒ‡Ú‡ ̇ Ò˙‚Ô‡‰ÂÌË ÏÂÊ‰Û ÛÒÚ‡ÌÓ‚Â̇ڇ ÒÚÛÍÚÛ̇ ‡ÌÓχÎËfl ‚ åêí (̇Ô. ‰‚ÓÈ̇ Ô‡ÚÓÎÓ„Ëfl), ÍÎËÌ˘ÌËÚ Ë/ËÎË ÖÖÉ ı‡‡ÍÚÂËÒÚËÍË (20,26). 3. ÑÓÍÛÏÂÌÚË‡Ì ̇ ÙÛÌ͈ËÓ̇ÎÂÌ ‰ÂÙˈËÚ Ë ‚˙ÁÏÓÊÌË ‰ÂÙˈËÚË ˜ÂÁ ‰ÌÓ ËÎË ÌflÍÓÎÍÓ ÓÚ ÒΉÌËÚ ËÁÒΉ‚‡ÌËfl: ÒÔˆˇÎËÁË‡Ì‡ Ì‚ÓÔÒËıÓÎӄ˘̇ ÓˆÂÌ͇, SPECT (single photon emission computed tomography) Ë PET (positron emission tomography) (1,16,19,20,26). óÂÁ ËÍÚ‡Î̇ڇ SPECT Ò ‚ËÁÛ‡ÎËÁË‡ ıËÔÂÔÂÙÛÁËflÚ‡ ‚ ӷ·ÒÚÚ‡ ̇ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇, ͇ÚÓ Ó˘Â ÔÓ-ÚӘ̇  ËÌÙÓχˆËflÚ‡ ˜ÂÁ ÔË·„‡Ì ̇ ÒÛ·Ú‡ÍˆËfl ̇ Ó·‡ÁËÚÂ, ÔÓÎÛ˜ÂÌË ˜ÂÁ ËÌÚÂËÍÚ‡Î̇ Ë ËÍÚ‡Î̇ SPECT ÔË ÛÒÔÓ‰ÌÓ ÔÓ‚Âʉ‡Ì‡ åêí (Ú.̇. subtraction ictal SPECT co-registered to MRI = SISCOM SPECT) (23). ïËÔÓÏÂÚ‡·ÓÎËÁÏ˙Ú ‚ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇, ÛÒÚ‡ÌÓ‚ÂÌ ˜ÂÁ ËÌÚÂËÍÚ‡Î̇ êÖí,  ÓÚ ÓÒÓ·ÂÌÓ Á̇˜ÂÌËÂ, ÓÒÓ·ÂÌÓ ÔË ÌflÍÓË ÙÓÏË Ì‡ ÙÓ͇ÎÌË ÂÔËÎÂÔÒËË, ̇Ô. ÚÂÁË Ò ÏÌÓÊÂÒÚ‚ÂÌË Ó„Ìˢ‡, Ë ÔË ÚÛ‰ÌÓÒÚË ‚ ÓÔ‰ÂÎflÌÂÚÓ Ì‡ Ô˙‚˘̇ڇ ÂÔËÎÂÔÚÓ„ÂÌ̇ ÁÓ̇ (19,20,26,29,33). èË ÌflÍÓË Ô‡ˆËÂÌÚË ÏÓÊ ‰‡ Ò ̇ÎÓÊË ËÁ‚˙¯‚‡ÌÂÚÓ Ì‡ ÔÂıӉ̇ Ù‡χÍÓÎӄ˘̇ Ë̇ÍÚË‚‡ˆËfl ̇ Ó„‡Ì˘ÂÌË ÏÓÁ˙˜ÌË ‡ÈÓÌË (ËÌÚ‡Í‡ÓÚˉÂÌ Ë ÒÂÎÂÍÚË‚ÂÌ WADA ÚÂÒÚ) (16,26). íÂÁË ËÁÒΉ‚‡ÌËfl Ò‡ ‚‡ÊÌË ‰ÓÔ˙ÎÌÂÌËfl Í˙Ï ‰‡ÌÌËÚ ÓÚ Ì‚ÓÎӄ˘ÌËfl ÒÚ‡ÚÛÒ, Ì‚ÓÔÒËıÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡ÌÂ Ë ÖÖÉ ÔÓ ÓÚÌÓ¯ÂÌË ‰ÂÙËÌË‡ÌÂÚÓ Ì‡ ÁÓ̇ڇ ̇ ÙÛÌ͈ËÓ̇ÎÂÌ ‰ÂÙˈËÚ (26). 4. ÖÎÂÍÚÓÙËÁËÓÎӄ˘̇ ÎÓ͇ÎËÁ‡ˆËfl ̇ ◊ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇”. ÖÖÉ-ËÁÒΉ‚‡ÌÂÚÓ ÓÒÚ‡‚‡ ̇Ȃ‡ÊÌËflÚ ÏÂÚÓ‰ Á‡ ÓÔ‰ÂÎflÌ ̇ Ôӂ˜ÂÚÓ ÓÚ ÔÓÒÓ˜ÂÌËÚ ÔÓ-„Ó ÁÓÌË: ÒËÏÔÚÓχÚÓ„ÂÌ̇, ËËÚ‡Ú˂̇ Ë ÁÓ̇ڇ ̇ ̇˜‡ÎÓ Ì‡ ÔËÒÚ˙ÔËÚ (1,2,11,17,20,22,25,26,29,34). ᇉ˙ÎÊËÚÂÎÌÓ Ò ÔÓ-

61

‚Âʉ‡ ‚ˉÂÓ-ÖÖÉ ÏÓÌËÚÓË‡ÌÂ, ‡ ÔË ÌÂÓ·ıÓ‰ËÏÓÒÚ – ÖÖÉ ˜ÂÁ ËÌÚ‡Í‡ÌˇÎÌË ÂÎÂÍÚÓ‰Ë. î‡Á‡ I. ê„ËÒÚË‡Ì ̇ ÌflÍÓÎÍÓ ÚËÔ˘ÌË ÔËÒÚ˙Ô‡ ‚ ÖÖÉ Ò Â‰ÌÓ‚ÂÏÂÌÂÌ ‚ˉÂÓ-Á‡ÔËÒ Ì‡ ‰ÓÒÚ‡Ú˙˜ÂÌ ·ÓÈ ÔËÒÚ˙ÔË (ÔÓ‰˙ÎÊËÚÂÎÌÓ ÌÂËÌ‚‡ÁË‚ÌÓ ÏÓÌËÚÓË‡ÌÂ) ‚ ‡ÏÍËÚ ̇ ÒÚ‡ˆËÓ̇ÂÌ ÔÂÒÚÓÈ ‚ Ò˙ÓÚ‚ÂÚÌËfl ÂÔËÎÂÔÚ˘ÂÌ ˆÂÌÚ˙ (8,16,22). èË ÌÂÓ·ıÓ‰ËÏÓÒÚ Ò Ô‰ÔËÂχ ÖÖÉ „ËÒÚ‡ˆËfl Ò Ú.̇. ÔÓÎÛËÌ‚‡ÁË‚ÌË ÂÎÂÍÚÓ‰Ë (ÒÙÂÌÓˉ‡ÎÌË ËÎË foramen-ovale-ÂÎÂÍÚÓ‰Ë). ÑÓÒÚ‡Ú˙˜Ì‡Ú‡ ËÌÚÂËÍÚ‡Î̇ ÖÖÉ ÔÓ ‚ÂÏ ̇ ·Û‰ÌÓÒÚ Ë ‚Ò˘ÍË ÒÚ‡‰ËË Ì‡ Ò˙Ìfl ÔÓÁ‚ÓÎfl‚‡ ÓÔ‰ÂÎflÌÂÚÓ Ì‡ ËËÚ‡Ú˂̇ڇ ÁÓ̇, Ú.Â. ÍÓÓ‚‡Ú‡ ӷ·ÒÚ, „ÂÌÂË‡˘‡ ËÌÚÂËÍÚ‡ÎÌËÚ ‡Áfl‰Ë (20,26). åËÌËχÎÌËflÚ Òڇ̉‡Ú Â ÔË·„‡ÌÂÚÓ Ì‡ 10-20 ÂÎÂÍÚӉ̇ ÒËÒÚÂχ Ò Ô‰ÌË ÚÂÏÔÓ‡ÎÌË (í1) ÂÎÂÍÚÓ‰Ë. Ç ÏÌÓ„Ó ˆÂÌÚÓ‚Â Ò ËÁÔÓÎÁ‚‡ ‡Á¯ËÂ̇ڇ 10-10 ÒËÒÚÂχ Á‡ ÔÓ-„ÓÎflχ ÔÓÒÚ‡ÌÒÚ‚Â̇ ÂÁÓβˆËfl (20,26). ëÔÓ‰ ÌflÍÓË ‡‚ÚÓË, ÒÙÂÌÓˉ‡ÎÌËÚ ÂÎÂÍÚÓ‰Ë ÔÓÁ‚ÓÎfl‚‡Ú ‰ÓÔ˙ÎÌËÚÂÎÌÓ ÛÚÓ˜Ìfl‚‡ÌÂ Ë Ò˙˘Ó Ò‡ Á‡‰˙ÎÊËÚÂÎÌË (26). Ç˙ÔÂÍË ËÒÍÓ‚ÂÚÂ, ÔË Ôӂ˜ÂÚÓ Ô‡ˆËÂÌÚË ÄÖå Ò ‰ۈË‡ Ë ‰ÓË ÒÔË‡ ÔÓ ‚ÂÏ ̇ ‚ˉÂÓ-ÖÖÉ-ÏÓÌËÚÓË‡ÌÂÚÓ Ò ˆÂÎ ÛÎÂÒÌfl‚‡Ì ËÁfl‚‡Ú‡ ̇ ÔËÒÚ˙ÔË Ë Û‚Â΢‡‚‡Ì ̇ ÂÔËÎÂÔÚËÙÓÏÂÌËÚ ‡Áfl‰Ë, ͇ÍÚÓ Ë ÒÍ˙Òfl‚‡Ì ̇ ÌÂËÌ‚‡Á˂̇ڇ Ù‡Á‡ (26). ᇠ‰‡ Ò ‰ÂÙËÌË‡ ÁÓ̇ڇ ̇ ̇˜‡ÎÓ Ì‡ ÔËÒÚ˙ÔËÚÂ,  ÌÂÓ·ıÓ‰ËÏÓ ‰‡ Ò Á‡Ô˯‡Ú ‚Ò˘ÍË ‚ˉӂ ÔËÒÚ˙ÔË (ÔÓÌ ̇˜‡ÎÓÚÓ ËÏ). åËÌËÏÛÏ 3 ‰Ó 5 ÔËÒÚ˙Ô‡ Úfl·‚‡ ‰‡ ·˙‰‡Ú ‰ÓÍÛÏÂÌÚË‡ÌË ˜ÂÁ ‚ˉÂÓ-ÖÖÉ-ÏÓÌËÚÓË‡Ì (20,26). î‡Á‡ II. ë‡ÏÓ ÔË Ï‡Î͇ ˜‡ÒÚ ÓÚ Ô‡ˆËÂÌÚËÚ (ÓÍÓÎÓ 20%), ÔÓ‡‰Ë ̉ÌÓÁ̇˜ÌË ÂÁÛÎÚ‡ÚË ÓÚ ÖÖÉ ËÁÒΉ‚‡ÌËflÚ‡ ËÎË ÎËÔÒ‡ ̇ ÍÓÌÍÓ‰‡ÌÚÌÓÒÚ ÏÂÊ‰Û ÍÎËÌ˘ÌËÚ ‰‡ÌÌË, ÂÁÛÎÚ‡ÚËÚ ÓÚ ÛÚËÌ̇ڇ ÖÖÉ, ÓÚ Ì‚ÓËÁÓ·‡Áfl‚‡˘ËÚÂ, ÙÛÌ͈ËÓ̇ÎÌËÚÂ Ë Ì‚ÓÔÒËıÓÎӄ˘ÌËÚ ËÁÒΉ‚‡ÌËfl, Ò Ô‰ÔËÂχ ÔÓ-̇ڇÚ˙¯ÌÓ, Ú.̇. ËÌ‚‡ÁË‚ÌÓ ÏÓÌËÚÓË‡ÌÂ. í‡ÍÓ‚‡ ÏÓÌËÚÓË‡Ì Ò ̇·„‡ Ë ÔË ÌÂÓ·ıÓ‰ËÏÓÒÚ ÓÚ ÔÓ-„ÓÎflχ ÔˆËÁÌÓÒÚ Á‡ ËÁ·Ó‡ ̇ ıËÛ„˘ÂÌ ÔÓ‰ıÓ‰, ̇ÔËÏÂ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇, ÍÓflÚÓ Úfl·‚‡ ‰‡ ·˙‰Â ÂÁˆË‡Ì‡,  ‡ÁÔÓÎÓÊÂ̇ Ò‰ Ó·¯Ë̇ ÂÎÓÍ‚ÂÌÚ̇ ÁÓ̇. (26). 5. ÑÓÔ˙ÎÌËÚÂÎÌË Ì‚ÓÙËÁËÓÎӄ˘ÌË ËÁÒΉ‚‡ÌËfl. åÓ„‡Ú ‰‡ ·˙‰‡Ú Ôӂ‰ÂÌË ÔÂ‰Ë ËÎË ÔÓ ‚ÂÏ ̇ ÓÔÂ‡ˆËflÚ‡, ͇ÚÓ ÚÛÍ Ò ‚Íβ˜‚‡Ú ‚ÓÍË‡ÌË ÔÓÚÂ̈ˇÎË, ÏÓÁ˙˜ÌÓ ÙÛÌ͈ËÓ̇ÎÌÓ Í‡ÚË‡Ì (˜ÂÁ ÂÎÂÍÚÓÒÚËÏÛ·ˆËfl), χ„ÌÂÚÓÂ̈ÂÙ‡ÎÓ„‡ÙËfl (MEG), ÂÎÂÍÚÓÍÓÚËÍÓ„‡ÙËfl (ECoG) Ë Ï‡„ÌËÚ̇ ÒÚËÏÛ·ˆËfl (24,26). éÒÌÓ‚ÌÓÚÓ ËÏ Á̇˜ÂÌË  Á‡ ÓÔ‰ÂÎflÌ ̇ ÂÎÓÍ‚ÂÌÚ̇ڇ ÁÓ̇, Ú.Â. ÏÓÁ˙˜Ì‡Ú‡ ÍÓ‡, ÓÚ„Ó‚Ó̇ Á‡ ÓÒ˙˘ÂÒÚ‚fl‚‡ÌÂÚÓ Ì‡ ‰‡‰Â̇ ÙÛÌ͈Ëfl. á‡Â‰ÌÓ Ò Ô˙Î̇ڇ ÂÁÂ͈Ëfl ̇ ÂÔËÎÂÔÚÓ„ÂÌ̇ڇ ÁÓ̇ Ò˙ı‡Ìfl‚‡ÌÂÚÓ Ì‡ Ú‡ÁË ÍÓ‡  ÓÚ Ó„ÓÏÌÓ Á̇˜ÂÌË Á‡ Í‡ÈÌËfl ËÁıÓ‰ ÓÚ ÓÔÂ‡ˆËflÚ‡ (26). Ç˙ÔÂÍË ˜Â ‚Ò Ӣ MEG  ËÁÒΉ‚‡Ì ÓÚ ÂÍÒÔÂËÏÂÌÚ‡ÎÌÓ ÂÒÚÂÒÚ‚Ó Ë Ì  ¯ËÓÍÓ ËÁÔÓÎÁ‚‡Ì‡, Úfl ‰ÓÔË̇Òfl Ò˙˘ÂÒÚ‚ÂÌÓ Ë Á‡ ÔˆËÁÌÓÚÓ ÓÔ‰ÂÎflÌ ̇ ËËÚ‡Ú˂̇ڇ ÁÓ̇ (24,26). 6. èÓ‰Ó·ÌÓ Ì‚ÓÔÒËıÓÎӄ˘ÌÓ ËÁÒΉ‚‡ÌÂ. éÚ ÒÔˆˇÎËÒÚË Ì‚ÓÔÒËıÓÎÓÁË Ò ËÁ‚˙¯‚‡ Ó·˘‡ ÍÓ„ÌËÚ˂̇ ÓˆÂÌ͇, ÓÔ‰ÂÎflÌ ̇ ıÂÏËÒÙÂ̇ ‰ÓÏË̇ÚÌÓÒÚ, ÓˆÂÌ͇ ̇ Ô‡ÏÂÚ, ‚ÌËχÌËÂ, ÙÓÌÚ‡ÎÌË ÙÛÌ͈ËË, ˜, ÁËÚÂÎÌÓ-ÔÓÒÚ‡ÌÒÚ‚ÂÌË ÙÛÌ͈ËË. ç‡ÔÓÒΉ˙Í ‚Ò ÔÓ-„ÓÎflÏÓ Á̇˜ÂÌË Ôˉӷ˂‡ ÙÛÌ͈ËÓ̇Î̇ڇ åêí (fMRI) Á‡ ËÁÒΉ‚‡Ì ̇ ˜, Ô‡ÏÂÚ, ÏÓÚÓË͇, ‡ ‚ ‰ÓÔ˙ÎÌÂÌË ËÎË ÔË ÎËÔÒ‡ ̇ ÍÓÌÍÓ‰‡ÌÚÌÓÒÚ ‚ ÂÁÛÎÚ‡ÚËÚ Ò ËÁ‚˙¯‚‡ Ë ÒÂÎÂÍÚË‚ÂÌ WADA ÚÂÒÚ Ì‡ Â˜Â‚Ë Ë Ô‡ÏÂÚÓ‚Ë ÙÛÌ͈ËË (ÔË ‚˙Á‡ÒÚÌË Ë ÍÓÓÔÂ‡ÚË‚ÌË „ÓÎÂÏË ‰Âˆ‡) (16,22,26,29).


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

7. èÒËıˇÚ˘̇ ÓˆÂÌ͇ ̇ Ò˙ÒÚÓflÌËÂÚÓ Ì‡ Ô‡ˆËÂÌÚ‡. èË·„‡Ú Ò Ò˙ÓÚ‚ÂÚÌË ÚÂÒÚÓ‚Â Á‡ ÓˆÂÌ͇ ÒÔÓ‰ ‚˙ÁÏÓÊÌÓÒÚËÚÂ, ‚ÍÎ. ‚˙Á‡ÒÚÚ‡, ‚ ‡ÏÍËÚ ̇ ËÌÚÂ‚˛ Ë ËÁÔÓÎÁ‚‡Ì ̇ ÒÔˆËÙ˘ÌË Ò͇ÎË Á‡ ‰ÂÔÂÒËfl, Ú‚ÓÊÌÓÒÚ, ΢ÌÓÒÚ Ë ‰. (1,16). ëÔÓ‰ ‚ÓÔÂÈÒÍËÚ Òڇ̉‡ÚË, Á‡ ÔÓ‚Âʉ‡ÌÂÚÓ Ì‡ ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚË͇ ̇ ÂÔËÎÂÔÒËËÚ Ëχ ËÁËÒÍ‚‡ÌËfl Í˙Ï ˆÂÌÚÓ‚ÂÚÂ, ‚ ÍÓËÚÓ Úfl Ò ËÁ‚˙¯‚‡ (16). í ҇ ÒΉÌËÚÂ: 1. ç‡Î˘Ë ̇ ÓÒÌӂ̇ „ÛÔ‡ (ÂÍËÔ) ÓÚ ÒÔˆˇÎËÒÚË, ‚Íβ˜‚‡˘‡ Ì‚ÓÙËÁËÓÎÓ„, Ì‚ÓÎÓ„ Ë ÓÔËÚÂÌ Ì‚ÓıËÛ„. 2. åËÌËÏÛÏ 25 ÓÔÂ‡ˆËË „Ӊ˯ÌÓ ‚ Ò˙ÓÚ‚ÂÚÌËfl ˆÂÌÚ˙ Á‡ ÔÓ‰‰˙ʇÌÂ Ë Û‚Â΢‡‚‡Ì ̇ ÌÂÓ·ıÓ‰ËÏÓÚÓ ÌË‚Ó Ì‡ ÂÍÒÔÂÚÌÓÒÚ. 3. ê„ÛÎfl̇ ËÌÚÂ‰ËÒˆËÔÎË̇̇ ‡·ÓÚ‡ ̇ ÂÍËÔ‡ Ò Ì‚ÓÔ‰ˇÚË, Ì‚Ó‡ÌÂÒÚÂÁËÓÎÓÁË, Ì‚ÓÔÒËıˇÚË, Ì‚Ó‡‰ËÓÎÓÁË, Ì‚ÓÔ‡ÚÓÎÓÁË Ë Ì‚ÓÔÒËıÓÎÓÁË, ͇ÍÚÓ Ë ÒÔˆˇÎËÒÚË ‚ ӷ·ÒÚÚ‡ ̇ ÌÛÍ·̇ڇ ωˈË̇ Ë ÚÂıÌ˘ÂÒÍË ÔÂÒÓ̇Î. 4. èË ÔÓ‚Âʉ‡Ì ̇ ËÌ‚‡ÁË‚ÌË ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ËÁÒΉ‚‡ÌËfl - ̇΢ˠ̇ ÓÚ‰ÂÎÂÌË Á‡ ËÌÚÂÌÁË‚ÌÓ ÏÓÌËÚÓË‡ÌÂ Ë Ì‚ÓıËÛ„˘ÌÓ ÓÚ‰ÂÎÂÌËÂ. 5. ê„ÛÎflÌÓ ÔÓÒΉfl‚‡Ì ̇ Ô‡ˆËÂÌÚËÚÂ Ò ËÁÒΉ‚‡ÌËfl Á‡ ÏËÌËÏÛÏ 5 „Ó‰ËÌË. 6. ìÒÎÓ‚Ëfl Á‡ ÔÓ‰˙ÎÊËÚÂÎÌÓ ‚ˉÂÓ-ÖÖÉ ÏÓÌËÚÓË‡ÌÂ. 7. ëÔÓÒÓ·ÌÓÒÚ Á‡ ÔˆÂÌ͇ ̇ ÌÂÓ·ıÓ‰ËÏÓÒÚÚ‡ ÓÚ ËÌ‚‡ÁË‚ÌÓ (ËÎË ËÌÚ‡ÓÔÂ‡ÚË‚ÌÓ) ÖÖÉ-ÏÓÌËÚÓË‡ÌÂ. Ç˙ÁÏÓÊÌÓÒÚ Á‡ 24-˜‡ÒÓ‚Ó ‡ÍÚË‚ÌÓ Ì‡·Î˛‰ÂÌË ‚ ÚÂÁË ÒÎÛ˜‡Ë. ëÔÓ‰ Ò˙‚ÂÏÂÌÌËÚ ‡Á·Ë‡ÌËfl, ‚˙ÔÂÍË ˜Â  ÔÓχÎÍÓ ËÌ‚‡Á˂̇ Ë ÔÓ-‚ÚË̇ ÓÚ ıÓÌ˘ÌÓ ËÏÔ·ÌÚË‡ÌËÚ ÒÛ·‰Û‡ÎÌË ËÎË ‰˙ηÓÍË ÂÎÂÍÚÓ‰Ë, ËÌÚ‡ÓÔÂ‡Ú˂̇ ÖCoG  ÓÔ‡‚‰‡Ì‡ Ò‡ÏÓ ÔË åêí-Ì„‡Ú˂̇ ̇ıӉ͇ Ë ÔÓ‰ÓÁË‡Ì‡ ÎÂÁËÓÌ̇ ÂÔËÎÂÔÚÓ„ÂÌ̇ Ú˙͇Ì, Á‡ ÓÔ‰ÂÎflÌ ̇ ËËÚ‡Ú˂̇ڇ ÁÓ̇ (26). Ä·ÒÓβÚÌÓ ËÁÍβ˜ÂÌË  MTLE. äËÚÂËËÚ Á‡ ‚˙ÁÏÓÊ̇ ıËÛ„Ëfl ·ÂÁ ËÌ‚‡Á˂̇ ‰Ë‡„ÌÓÒÚË͇ Ò‡ (17,20,26): 1. èË MTLE ● åÂÁˇÎ̇ ÚÂÏÔÓ‡Î̇ ÎÂÁËfl ‚ åêí Ë/ËÎË ÚÂÏÔÓ‡ÎÂÌ ıËÔÓÏÂÚ‡·ÓÎËÁ˙Ï ‚ PET ● ÑÓÏËÌË‡˘Ë ËÌÚÂËÍÚ‡ÎÌË ÓÒÚËfl Ë ËÍÚ‡ÎÌÓ ÖÖÉ Ì‡˜‡ÎÓ, Ò˙‚Ô‡‰‡˘Ë Ò ÎÂÁËflÚ‡ ● ëÂÏËÓÎÓ„Ëfl ̇ ÔËÒÚ˙ÔËÚÂ, Ò˙‚Ô‡‰‡˘‡ Ò ÎÂÁËflÚ‡ ● ç‚ÓÍÓ„ÌËÚË‚ÌÓ / WADA ËÁÒΉ‚‡ÌÂ, Ò˙‚Ô‡‰‡˘Ó Ò ÎÂÁËflÚ‡ ● ãËÔÒ‡ ̇ ÌÂÒ˙‚Ô‡‰‡˘Ë ‰‡ÌÌË 2. èË ÌÂÓÍÓÚË͇Î̇ ÂÔËÎÂÔÒËfl ● ãÂÁËfl ‚ åêí ● àÌÚÂËÍÚ‡ÎÌË ÓÒÚËfl Ë ËÍÚ‡ÎÌÓ ÖÖÉ Ì‡˜‡ÎÓ, Ò˙‚Ô‡‰‡˘Ë Ò ÎÂÁËflÚ‡ ● ëÂÏËÓÎÓ„Ëfl ̇ ÔËÒÚ˙ÔËÚÂ, Ò˙‚Ô‡‰‡˘‡ Ò ÎÂÁËflÚ‡ ● îÛÌ͈ËÓ̇ÎÌË Ì‡Û¯ÂÌËfl, Ò˙‚Ô‡‰‡˘Ë Ò ÎÂÁËflÚ‡ ● ãËÔÒ‡ ̇ ÌÂÒ˙‚Ô‡‰‡˘Ë ‰‡ÌÌË àÁÔÓÎÁ‚‡ÌÂÚÓ Ì‡ ÒÛ·‰Û‡ÎÌË ËÎË ‰˙ηÓÍË (ÒÚÂÂÓÚ‡ÍÚ˘ÌÓ ËÏÔ·ÌÚË‡ÌË) ÂÎÂÍÚÓ‰Ë Ò ̇·„‡ ÔË ÎËÔÒ‡ ̇ ÒÚÛÍÚÛ̇ ÎÂÁËfl ‚ Ì‚ÓËÁÓ·‡Áfl‚‡˘ËÚ ËÁÒΉ‚‡ÌËfl Ë ÔË ‰Ë‚Â„ÂÌÚÌË ÌÂËÌ‚‡ÁË‚ÌË ‰‡ÌÌË, ͇ÚÓ Ì‡ÔËÏÂ ‰‚ ÎÂÁËË ÓÚ Â‰Ì‡ ÒÚ‡Ì‡ Ò ÌÂflÒ̇ ÓÎfl ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÂÔËÎÂÔÚÓ„ÂÌÂÁ‡Ú‡ (̇Ô. ÚÛ·ÂÓÁ̇ ÒÍÎÂÓÁ‡) Ë Ò˙‚Ô‡‰ÂÌË ̇ ‰‡ÌÌËÚ Á‡ ÒÂÏËÓÎÓ„ËflÚ‡ Ë åêí ÎÂÁËflÚ‡, ÌÓ ÍÓÌÚ‡Î‡ÚÂ‡Î̇ ÖÖÉ (Á‡ ËÁÍβ˜‚‡Ì ̇ هί˂‡ ·ÚÂ‡ÎËÁ‡ˆËfl ̇ ÔÓ‚˙ıÌÓÒÚ̇ڇ ÖÖÉ) (8,11,26,34).

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áÄäãûóÖçàÖ ä‡ÚÓ ÓÒÌÓ‚ÓÔÓ·„‡˘ ÔË̈ËÔ ‚ ÂÔËÎÂÔÚ˘̇ڇ ıËÛ„Ëfl Ò ÔËÂχ Ô‡‚ËÎÓÚÓ, ˜Â Ò‡ÏÓ ÙÓ͇ÎÌË ËÎË ‰Ó· ÎÓ͇ÎËÁË‡ÌË ÂÔËÎÂÔÒËË ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÚÂÚË‡ÌË ÓÔÂ‡ÚË‚ÌÓ. èÓ̇ÒÚÓfl˘ÂÏ Í‡ÚÓ ‚ÚÓË ÔË̈ËÔ Ò ÛÚ‚˙ʉ‡‚‡ Òı‚‡˘‡ÌÂÚÓ Á‡ ‚˙ÁÏÓÊÌÓ Ì‡È-‡Ì̇ ÓÔÂ‡Ú˂̇ ËÌÚÂ‚Â̈Ëfl Ò ˆÂÎ ËÁ·fl„‚‡Ì ̇ Ì„‡ÚË‚ÌËÚ ÔÓÒÎÂ‰ËˆË ÓÚ ‰˙΄ӄӉ˯ÌÓÚÓ ÔËÎÓÊÂÌË ̇ ÄÖå Ë ˜ÂÒÚËÚ Ë/ËÎË ÚÂÊÍË ÂÔËÎÂÔÚ˘ÌË ÔËÒÚ˙ÔË ‚˙ıÛ Í‡˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ Ë ÍÓ„ÌËÚË‚ÌÓÚÓ ‡Á‚ËÚËÂ. íÓ‚‡  ‚˙ÁÏÓÊÌÓ Ò‡ÏÓ ÒΉ ÔˆËÁ̇ ÔÂıËÛ„˘̇ ‰Ë‡„ÌÓÒÚË͇ Ë ËÌÚÂ‰ËÒˆËÔÎË̇̇ ÔˆÂÌ͇ ̇ ‚ÒÂÍË ÓÚ‰ÂÎÂÌ ÒÎÛ˜‡È Ò ˆÂΠχÍÒËχÎÌÓ Ó„‡Ì˘‡‚‡Ì ̇ ËÌ‚‡ÁË‚ÌËfl ÔÓ‰ıÓ‰, ÓÔÂ‡ÚË‚ÌËfl ËÒÍ Ë ÔÓÒÚÓÔÂ‡ÚË‚ÌËÚ ‰ÂÙˈËÚË. å‡Í‡ ̇ ÙÓ̇ ̇ Ó„‡Ì˘ÂÌË ÂÒÛÒË ‚ ̇¯‡Ú‡ ÒÚ‡Ì‡, ÔË Ô‡‚ËÎÌÓ ‚˙ÁÔËÂχÌ ̇ Ò˙‚ÂÏÂÌÌËÚ ÚÂÓÂÚ˘ÌË ÍÓ̈ÂÔˆËË Ë Ô‡ÍÚ˘ÂÒÍË ÒÚ‡Ú„ËË ‚ ÂÔËÎÂÔÚ˘̇ڇ ıËÛ„Ëfl, ÚÓÁË ËÁÍβ˜ËÚÂÎÌÓ ÛÒÔ¯ÂÌ ÚÂ‡Ô‚Ú˘ÂÌ ÔÓ‰ıÓ‰ ·Ë ÏÓ„˙Î ‰‡ Ëχ ‰ÓÒÚÓÈÌÓ ÏflÒÚÓ Ò‰ Θ·ÌËÚ ‚˙ÁÏÓÊÌÓÒÚË ÔË ÎÓ͇ÎËÁ‡ˆËÓÌÌÓ-Ò‚˙Á‡ÌË ÂÙ‡ÍÚÂÌË ÂÔËÎÂÔÒËË. ãàíìêÄíìêÄ 1. 2. 3. 4. 5. 6. 7.

8.

9. 10. 11. 12. 13. 14. 15.

16. 17.

18. 19. 20. 21. 22.

Baumgartner, C., Czech, T., Feucht, M., Schindler, E., Podreka, I. [Presurgical diagnosis of epilepsy and surgical epilepsy treatment]. Wien Klin Wochenschr 1997; 109: 180-91. Baumgartner, C., Lindinger, G., Lurger, S., et al. [Prolonged video EEG monitoring in differential diagnosis of seizures and in presurgical epilepsy diagnosis. Wien Med Wochenschr 1998; 148: 2-8. Berg, A.T., Vickrey, B.G., Langfitt, J.T., et al. The multicenter study of epilepsy surgery: recruitment and selection for surgery. Epilepsia. 2003; 44: 1425-33. Boesebeck, F., Schulz, R., May, T., Ebner, A. Lateralizing semiology predicts the seizure outcome after epilepsy surgery in the posterior cortex. Brain 2002; 125: 2320-2331. Capizzano, A.A., Vermathen, P., Laxer, K.D., et al. When drugs don't work: An algorithmic approach to medically intractable epilepsy. Neurology 2000; 55: 1780-1784. Colombo, N., Tassi, L., Galli, C., et al. Focal cortical dysplasias: MR imaging, histopathologic, and clinical correlations in surgically treated patients with epilepsy. AJNR Am J Neuroradiol. 2003;24:724-33. Commission on Neurosurgery of the International League Against Epilepsy (ILAE) 1997-2001:, Wieser, H.G., Blume, W.T., Fish, D., Goldensohn, E., Hufnagel, A., King, D., Sperling, M.R., Luders, H.O. Proposal for a New Classification of Outcome with Respect to Epileptic Seizures Following Epilepsy Surgery Epilepsia 2001; 42: 282–286. Cross, J.H., Jayakar, P., Nordli, D., Delalande, O., Duchowny, M., Wieser, H.G., Guerrini, R., Mathern, G.W. Proposed Criteria for Referral and Evaluation of Children for Epilepsy Surgery: Recommendations of the Subcommission for Pediatric Epilepsy Surgery Epilepsia 2006; 47: 952–959. Devinsky, O. Patients with Refractory Seizures. NEJM 1999; 340: 1565-1570. Dewar, S., Passaro, E., Fried, I., Engel, J.Jr. Intracranial electrode monitoring for seizure localization: indications, methods and the prevention of complications. J Neurosci Nurs 1996; 28: 280-4, 289-92. Diehl, B., Luders, H.O. Temporal lobe epilepsy: when are invasive recordings needed? Epilepsia 2000; 41(Suppl 3): S61-74. Dlugos, D.J. The early identification of candidates for epilepsy surgery. Arch Neurol 2001; 58: 1543-6. Engel, J. Jr. Current concepts: Surgery for seizures. N Engl J Med. 1996; 334: 647-52. Engel, J. Jr., A Greater role for surgical treatment of epilepsy: why and when? Epilepsy Curr 2003; 3: 37–40. Engel, J.Jr., Wiebe, S., French, J., et al. Practice parameter: Temporal lobe and localized neocortical resections for epilepsy. Report of the Quality Standards Subcommittee of the American Academy of Neurology, in Association with the American Epilepsy Society and the American Association of Neurological Surgeons. Epilepsia 2003; 44: 741–751. European Federation of Neurological Societies Task Force. Pre-surgical evaluation for epilepsy surgery - European standards. Eur J Neurol. 2000; 7: 11922. Francione S, Vigliano P, Tassi L, Cardinale F, Mai R, Lo Russo G, Munari C. Surgery for drug resistant partial epilepsy in children with focal cortical dysplasia: anatomical-clinical correlations and neurophysiological data in 10 patients. J Neurol Neurosurg Psychiatry 2003; 74: 1493-501. Huppertz, H.J., Grimm, C., Fauser, S., Ât al. Enhanced visualization of blurred gray-white matter junctions in focal cortical dysplasia by voxel-based 3D MRI analysis. Epilepsy Res 2005; 67: 35-50. Hwang, S.I., Kim, J.H., Park, S.W., et al. Comparative analysis of MR imaging, positron emission tomography, and ictal single-photon emission CT in patients with neocortical epilepsy. Am J Neuroradiol 2001; 22: 937-946. Luders, H.O., Najm, I., Nair, D., Widdess-Walsh, P., Bingman, W. The epileptogenic zone: general principles. Epileptic Disord. 2006; 8(Suppl 2): 19. McBride, M.C., Bronstein, K.S., Bennett, B., Erba, G., Pilcher, W., Berg, M.J. Failure of standard magnetic resonance imaging in patients with refractory temporal lobe epilepsy. Arch Neurol 1998; 55: 346-348. Munari, C., Broggi, G., Scerrati, M. Study Group of Functional Neurosurgery


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

of the Italian Society of Neurosurgery. Epilepsy surgery: guidelines for minimum standard equipment and organization. J Neurosurg Sci 2000;44: 173-6. 23. O'Brien, T.J., So, E.L., Mullan, B.P., et al. Subtraction ictal SPECT co-registered to MRI improves clinical usefulness of SPECT in localizing the surgical seizure focus. Neurology 1998; 50: 445-54. 24. Pataraia, E., Simos, P.G., Castillo, E.M., et al. Does magnetoencephalography add to scalp video-EEG as a diagnostic tool in epilepsy surgery? Neurology 2004; 62: 943-948. 25. Quarato, P.P., Di Gennaro, G., Mascia, A., et al. Temporal lobe epilepsy surgery: different surgical strategies after a non-invasive diagnostic protocol. J Neurol Neurosurg Psychiatry 2005; 76: 815-824. 26. Rosenow, F., Luders, H.O. Presurgical evaluation of epilepsy. Brain 2001; 124: 1683-1700. 27. Sillanpaa, M., Jalava, M., Kaleva, O., Shinnar, S. Long-term prognosis of seizures with onset in childhood. NEJM 1999; 338: 1715-1722. 28. Snead O.C. 3rd. Surgical treatment of medically refractory epilepsy in childhood. Brain Dev 2001; 23: 199-207. 29. So E.L. Integration of EEG, MRI, and SPECT in localizing the seizure focus for epilepsy surgery. Epilepsia 2000; 41(Suppl 3): S48-S54. 30. Tassi, L, Colombo, N, Cossu, M, et al. Electroclinical, MRI and neuropathological study of 10 patients with nodular heterotopia, with surgical outcomes. Brain. 2005;128: 321-37. 31. Tassi, L., Colombo, N., Garbelli, R., et al. Focal cortical dysplasia: neu-

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ropathological subtypes, EEG, neuroimaging and surgical outcome. Brain. 2002; 125: 1719-32. 32. von Oertzen, J., Urbach, H., Jungbluth, S., et al. Standard magnetic resonance imaging is inadequate for patients with refractory focal epilepsy. J Neurol Neurosurg Psychiatry 2002; 73: 643-647. 33. Won, H.J., Chang, KH., Cheon, J.E., et al. Comparison of MR imaging with PET and ictal SPECT in 118 patients with intractable epilepsy. Am J Neuroradiol 1999; 20: 593-599. 34. Zumsteg, D., Wieser H.G. Presurgical evaluation: current role of invasive EEG. Epilepsia 2000; 41(Suppl.3): S55-S60.

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: Ñ- èÂÚfl ëÚ. ÑËÏÓ‚‡, ‰Ï ÑÂÚÒ͇ Ì‚ÓÎӄ˘̇ ÍÎËÌË͇, ìëÅÄãçè “ë‚.ç‡ÛÏ” – IV ÍÏ. ìÎ. “Ñ- ã. êÛÒ‚” ‹1, 1113 ëÓÙËfl íÂÎ: 9702 – 232 E-mail: pdimova@cablebg.net

é·ÁÓ îÄêåÄäéàäéçéåàäÄ à ÖèàãÖèëàü è. Ň··‡ÌÓ‚, á. á‡ı‡Ë‚ äÎËÌË͇ ÔÓ ç‚ÓÎÓ„Ëfl, å‰ˈËÌÒÍË ìÌË‚ÂÒËÚÂÚ, èÎÓ‚‰Ë‚ SUMMARY Epilepsy is a chronic disorder providing a significant medical and social burden. Its prevalence is constantly growing and the fact that it affects primarily children and young people is at the base of its social significance. The clinical and social characteristics of epilepsy are the reason economic analyses in this area to be constantly encouraged. There are a growing number of newer therapeutic opportunities being presented to the market carrying higher efficacy but at a higher cost. One of the main goals of health economics is to answer the question: How do recent developments in health care affect the clinical and social outcomes? Pharmacoeconomics is a relatively new specialty with methods that allow the effectiveness and adequacy of the diagnostic and therapeutic conduct to be evaluated on a larger scale. This provides the opportunity to evaluate not just the direct effect of the treatment on the disease, but also its prolonged medical, social, economic and personal consequences. For that reason any pharmacoeconomic research in the field of epilepsy on a local and global scale is significant and extremely valuable. êÖáûåÖ ÖÔËÎÂÔÒËflÚ‡  ¯ËÓÍÓ ‡ÁÔÓÒÚ‡ÌÂÌÓ Á‡·ÓÎfl‚‡ÌÂ Ò „ÓÎflÏÓ Ï‰ËÍÓ-ÒӈˇÎÌÓ Á̇˜ÂÌËÂ. óÂÒÚÓÚ‡Ú‡ ̇ ‡ÁÔÓÒÚ‡ÌÂÌËÂÚÓ ÏÛ Ì‡‡ÒÚ‚‡ ‚ ̇¯Ë ‰ÌË. á‡Òfl„‡ÌÂÚÓ Ì‡ ‰Âˆ‡ (‚ ÓÍÓÎÓ 50% ÓÚ ÒÎÛ˜‡ËÚÂ) Ë Ï·‰Ë ıÓ‡ (ÓÍÓÎÓ 75% ÓÚ ÒÎÛ˜‡ËÚÂ) Ò‡ ‚ ÓÒÌÓ‚‡Ú‡ ̇ „ÓÎflÏÓÚÓ ÒӈˇÎÌÓ Á̇˜ÂÌË ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ. éÔËÒ‡ÌËÚ ÓÒÓ·ÂÌÓÒÚË Ì‡ ÂÔËÎÂÔÒËflÚ‡ ͇ÚÓ Á‡·ÓÎfl‚‡Ì ҇ Ô˘Ë̇ڇ, ËÍÓÌÓÏ˘ÂÒÍËÚ ‡Ì‡ÎËÁË ‚ Ú‡ÁË Ó·Î‡ÒÚ ‰‡ ·˙‰‡Ú ÓÒÓ·ÂÌÓ Á̇˜ËÏË. Ç ‰Ì¯̇ڇ Ô‡ÍÚË͇ Ò Ô‰ÒÚ‡‚flÚ ‚Ò Ôӂ˜ ÌÓ‚Ë ‡ÌÚËÂÔËÎÂÔÚ˘ÌË Ï‰Ë͇ÏÂÌÚË Ò Ì‡‡ÒÚ‚‡˘‡ ÂÙË͇ÒÌÓÒÚ, ÌÓ Ë Ò ÔÓ-‚ËÒÓ͇ ˆÂ̇. ։̇ ÓÚ ÓÒÌÓ‚ÌËÚ Á‡‰‡˜Ë ̇ Á‰‡‚̇ڇ ËÍÓÌÓÏË͇  ‰‡ ‰‡‰Â ÓÚ„Ó‚Ó ̇ ‚˙ÔÓÒ‡ Í‡Í ÌÓ‚ÓÒÚËÚ ‚ Á‰‡‚ÂÓÔ‡Á‚‡ÌÂÚÓ ‚ÎËflflÚ ‚˙ıÛ Ó·˘ËÚ ÂÁÛÎÚ‡ÚË. î‡χÍÓËÍÓÌÓÏË͇ڇ  ‰̇ Ò‡‚ÌËÚÂÎÌÓ ÌÓ‚‡ ÒÔˆˇÎÌÓÒÚ ˜ËËÚÓ ÏÂÚÓ‰Ë ÔÓÁ‚ÓÎfl‚‡Ú ‰‡ Ò ӈÂÌË ‡‰ÂÍ‚‡ÚÌÓÒÚÚ‡ ̇ ‰Ë‡„ÌÓÒÚ˘ÌÓÚÓ Ë ÚÂ‡Ô‚Ú˘ÌÓÚÓ Ôӂ‰ÂÌË ÓÚ ÔÓ-¯ËÓ͇ „Ή̇ ÚӘ͇. í‡Í‡ ÒÚ‡‚‡ ‚˙ÁÏÓÊÌÓ ‰‡ Ò ÔˆÂÌË Ì ҇ÏÓ ÔÂÍËfl ÂÙÂÍÚ Ì‡ ‰‡‰Â̇ ÚÂ-

‡ÔËfl ‚˙ıÛ Ô‡ÚÓÎÓ„ËflÚ‡, ÌÓ Ë ÔÓ-ÓÚ‰‡Î˜ÂÌËÚ ‚˙‚ ‚ÂÏÂÚÓ Ï‰ˈËÌÒÍË, ÒӈˇÎÌË, ËÍÓÌÓÏ˘ÂÒÍË Ë Î˘ÌÓÒÚÌË ÔÓÒΉˈË. èÓ Ú‡ÁË Ô˘Ë̇ ÔÓÛ˜‚‡ÌËflÚ‡ ‚ Ú‡ÁË Ó·Î‡ÒÚ, ͇ÍÚÓ ‚ Ò‚ÂÚÓ‚ÂÌ Ú‡Í‡ Ë ‚ ÎÓ͇ÎÂÌ Ï‡˘‡·, Ò‡ ̇ÎÓÊËÚÂÎÌË Ë ËÁÍβ˜ËÚÂÎÌÓ Á̇˜ËÏË. ᇠ‚ÒÂÍË Ô‡ÍÚËÍÛ‚‡˘ ωˈËÌÒ͇ڇ ÔÓÙÂÒËfl  ÌÂÓ·ıÓ‰ËÏÓ ‰‡ Á̇Â, ˜Â Ì Ò˙˘ÂÒÚ‚Û‚‡ ÔÓ-ÒÍ˙ÔÓ ÒÚÛ‚‡˘Ó ΘÂÌË ÓÚ ÌÂÂÙÂÍÚË‚ÌÓÚÓ. ë˙‚ÂÏÂÌ̇ڇ ωˈË̇ ‚Ò Ôӂ˜ Ò Ô‚˙˘‡ ‚ å‰ˈË̇ ̇ ‰Ó͇Á‡ÚÂÎÒÚ‚‡Ú‡. íÓ‚‡ ÓÁ̇˜‡‚‡, ˜Â ¯ÂÌËÂÚÓ Ì‡ ÎÂ͇fl Á‡ Ôӂ‰ÂÌËÂÚÓ ÏÛ ÔË ‚ÒÂÍË ·ÓÎÂÌ Úfl·‚‡ ‰‡ Ò ÓÒÌÓ‚‡‚‡ ̇ Ò˙˘ÂÒÚ‚Û‚‡˘Ë Ó·ÂÍÚË‚ÌË ‰Ó͇Á‡ÚÂÎÒÚ‚‡, Ò˙„·ÒÛ‚‡ÌË Ò˙Ò Ò˙‚ÂÏÂÌÌÓÚÓ Ò˙ÒÚÓflÌË ̇ ̇Û͇ڇ. å‰Ë͇ÏÂÌÚÓÁÌÓÚÓ Î˜ÂÌËÂ, ÓÒÌÓ‚‡‚‡˘Ó Ò ̇ ‰Ó͇Á‡ÚÂÎÒÚ‚‡  Î˜ÂÌËÂ, ÍÓÂÚÓ Ò ÓÒÌÓ‚‡‚‡ ̇ Ó·ÂÍÚË‚ÌË ‰‡ÌÌË Á‡ ÂÙÂÍÚË‚ÌÓÒÚ, ·ÂÁÓÔ‡ÒÌÓÒÚ Ë ËÍÓÌÓÏ˘ÂÒ͇ ˆÂÎÂÒ˙Ó·‡ÁÌÓÒÚ. íÓ Úfl·‚‡ ‰‡ Ò ÓÒÌÓ‚‡‚‡ ̇ ‰‡ÌÌË, ÔÓÎÛ˜ÂÌË ÓÚ ÍÓÌÚÓÎË‡ÌË, ‡Ì‰ÓÏËÁË‡ÌË, ÍÎËÌËÍÓ-Ù‡χÍÓÎӄ˘ÌË ÔÓÛ˜‚‡ÌËfl, Ôӂ‰ÂÌË ‚ Ò˙ÓÚ‚ÂÚÒÚ‚ËÂ Ò ËÁËÒÍ‚‡ÌËflÚ‡ ̇ “ÑÓ·‡Ú‡ ÍÎËÌ˘̇ Ô‡ÍÚË͇”, ÍÎËÌËÍÓ-ÂÔˉÂÏËÓÎӄ˘ÌË ÔÓÛ˜‚‡ÌËfl, ÏÂÚ‡-‡Ì‡ÎËÁË. ч Ò Ô‡ÍÚËÍÛ‚‡ ڇ͇‚‡ ÚÂ‡ÔËfl ÓÁ̇˜‡‚‡ ‰ÓÊË‚ÓÚÂÌ ÔÓˆÂÒ Ì‡ ˆÂÎÂ̇ÒÓ˜ÂÌÓ ÔÓÛ˜‚‡ÌÂ Ë Ó·Ó„‡Úfl‚‡Ì ̇ ÒÓ·ÒÚ‚ÂÌËÚ ÔÓÁ̇ÌËfl ‚˙ıÛ ·ÓÎÂÒÚÌËÚ ‰ËÌËˆË Ë ÚÂ‡ÔËflÚ‡ ËÏ. ᇠӈÂÌ͇ ‡ˆËÓ̇ÎÌÓÒÚÚ‡ ̇ ÎÂ͇ÒÚ‚Â̇ڇ ÚÂ‡ÔËfl ͇ÚÓ ÍËÚÂËË ÒÎÛÊ‡Ú Ò˙ÓÚÌÓ¯ÂÌËÂÚÓ ÔÓÎÁ‡/ËÒÍ Ë Ò˙ÓÚÌÓ¯ÂÌËÂÚÓ ÔÓÎÁ‡/ÒÚÓÈÌÓÒÚ. é·ËÍÌÓ‚ÂÌÓ Ò ӷ˙˘‡ ÔÓ-„ÓÎflÏÓ ‚ÌËχÌË ̇ Ò˙ÓÚÌÓ¯ÂÌËÂÚÓ ÔÓÎÁ‡/ËÒÍ. ë‡ÏÓÒÚÓflÚÂÎÂÌ ‰flÎ ÓÚ ÍÎËÌ˘̇ڇ Ù‡χÍÓÎÓ„Ëfl ËÁÛ˜‡‚‡ Ò˙ÓÚÌÓ¯ÂÌËÂÚÓ ÔÓÎÁ‡/ÒÚÓÈÌÓÒÚ. î‡χÍÓËÍÓÌÓÏË͇ڇ ËÁÛ˜‡‚‡ ÓÚÌÓ¯ÂÌËÂÚÓ ÏÂÊ‰Û ÒÚÓÈÌÓÒÚÚ‡ Ë ÂÁÛÎÚ‡Ú‡ ÓÚ ÔË·„‡ÌÂÚÓ Ì‡ ÎÂ͇ÒÚ‚ÂÌÓÚÓ Ò‰ÒÚ‚Ó. ëÔÓ‰ ëáé, ÍÓ„‡ÚÓ ÎÂ͇ÒÚ‚ÂÌËÚ Ò‰ÒÚ‚‡ Ò‡ Ò˙ÔÓÒÚ‡‚ËÏË ÔÓ ÂÙÂÍÚË‚ÌÓÒÚ ÒÔÓ‰ ÔÓ‰·‡ÌË ÍËÚÂËË, ı‡‡ÍÚÂÌË Á‡ ‰‡‰ÂÌÓÚÓ Á‡·ÓÎfl‚‡ÌÂ, ÎÂ͇ÒÚ‚ÂÌËÚ „ÛÔË Ò Ò‡‚Ìfl‚‡Ú ÔÓ ·ÂÁÓÔ‡ÒÌÓÒÚ, ÔÓÌÓÒËÏÓÒÚ Ë ˆÂ̇. äÓÏÔÎÂÍÒÌËflÚ ÔÓ‰ıÓ‰ Í˙Ï ‡Ì‡ÎËÁ‡ ̇ ˆÂÎÂÒ˙Ó·‡ÁÌÓÒÚÚ‡ ̇ ÔË·„‡Ì ̇ ‡ÎÚÂ̇ÚË‚ÌË ÎÂ͇ÒÚ‚ÂÌË ‚˙Á‰ÂÈ-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÒÚ‚Ëfl ÒΉ‚‡ ‰‡ ·˙‰Â ÓÒÌÓ‚‡Ì ̇ ÒΉÌËÚ ÓÒÌÓ‚ÌË ÔË̈ËÔË: 1. ᇠ‰‡ Ò ̇Ô‡‚Ë Ô‡‚ËÎÂÌ ËÁ·Ó ÔË ‚ÁÂχÌ ̇ ÍÎËÌ˘ÌË Ë ‡‰ÏËÌËÒÚ‡ÚË‚ÌÓ-ÛÔ‡‚ÎÂ̘ÂÒÍË ¯ÂÌËfl  ÌÂÓ·ıÓ‰ËÏÓ ‰‡ Ò ÓÚÍËflÚ Ë ‡Á„Ή‡Ú ‚Ò˘ÍË Ò˙˘ÂÒÚ‚Û‚‡˘Ë ‡ÎÚÂ̇ÚË‚Ë. 2. ᇠӷÂÍÚË‚ÂÌ ËÁ·Ó Úfl·‚‡ ‰‡ Ò Ôӂ‰ Ò‡‚ÌËÚÂÎÂÌ ÍÓ΢ÂÒÚ‚ÂÌ ‡Ì‡ÎËÁ ̇ Ò˙˘ÂÒÚ‚Û‚‡˘ËÚ ‡ÎÚÂ̇ÚË‚ÌË ‚‡ˇÌÚË Á‡ ‰ÓÒÚË„‡Ì ̇ Ê·ÌËfl ÂÙÂÍÚ. ÖÔËÎÂÔÒËflÚ‡  ¯ËÓÍÓ ‡ÁÔÓÒÚ‡ÌÂÌÓ Á‡·ÓÎfl‚‡ÌÂ Ò „ÓÎflÏÓ Ï‰ËÍÓ-ÒӈˇÎÌÓ Á̇˜ÂÌËÂ. óÂÒÚÓÚ‡Ú‡ ̇ ‡ÁÔÓÒÚ‡ÌÂÌËÂÚÓ ÏÛ Ì‡‡ÒÚ‚‡ ‚ ̇¯Ë ‰ÌË. 燘‡ÎÓÚÓ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ Â Ô‰ËÏÌÓ ‚ ‰ÂÚÒ͇ڇ ‚˙Á‡ÒÚ. á‡Òfl„‡ÌÂÚÓ Ì‡ ‰Âˆ‡ (‚ ÓÍÓÎÓ 50% ÓÚ ÒÎÛ˜‡ËÚÂ) Ë Ï·‰Ë ıÓ‡ (ÓÍÓÎÓ 75% ÓÚ ÒÎÛ˜‡ËÚÂ) Ò‡ ‚ ÓÒÌÓ‚‡Ú‡ ̇ „ÓÎflÏÓÚÓ ÒӈˇÎÌÓ Á̇˜ÂÌË ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ. ᇷÓÎfl‚‡ÌÂÚÓ Ëχ ıÓÌ˘ÌÓ ‡Á‚ËÚËÂ, ÔÓ‡‰Ë ÍÓÂÚÓ Ò ̇·„‡ ‰˙΄ӄӉ˯ÌÓ Î˜ÂÌËÂ. Ç Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë ÂÙÂÍÚË‚ÌÓÒÚÚ‡ ̇ ΘÂÌËÂÚÓ Â ‚ËÒÓ͇ Ë ÂÙÂÍÚ Ò ÓÚ˜ËÚ‡ ÓÚÌÓÒËÚÂÎÌÓ ·˙ÁÓ Ë ÎÂÒÌÓ (1). Ç ÓÒÌÓ‚‡Ú‡ ̇ ‡‰ÂÍ‚‡Ú̇ڇ ÚÂ‡ÔËfl ÎÂÊË ËÁ·Ó˙Ú Ì‡ Ô‡‚ËÎÌËfl ωË͇ÏÂÌÚ, ÔÒËıÓÎӄ˘ÂÒÍË ÔÓ‰ıÓ‰ Ë Ôӂ‰ÂÌËÂ. éÔËÒ‡ÌËÚ ÓÒÓ·ÂÌÓÒÚË Ì‡ ÂÔËÎÂÔÒËflÚ‡ ͇ÚÓ Á‡·ÓÎfl‚‡Ì ҇ Ô˘Ë̇ڇ, ËÍÓÌÓÏ˘ÂÒÍËÚ ‡Ì‡ÎËÁË ‚ Ú‡ÁË Ó·Î‡ÒÚ ‰‡ ·˙‰‡Ú ÓÒÓ·ÂÌÓ Á̇˜ËÏË. Ç ‰Ì¯̇ڇ Ô‡ÍÚË͇ Ò Ô‰ÒÚ‡‚flÚ ‚Ò Ôӂ˜ ÌÓ‚Ë ‡ÌÚËÂÔËÎÂÔÚ˘ÌË Ï‰Ë͇ÏÂÌÚË Ò Ì‡‡ÒÚ‚‡˘‡ ÂÙË͇ÒÌÓÒÚ, ÌÓ Ë Ò ÔÓ-‚ËÒÓ͇ ˆÂ̇. ։̇ ÓÚ ÓÒÌÓ‚ÌËÚ Á‡‰‡˜Ë ̇ Á‰‡‚̇ڇ ËÍÓÌÓÏË͇  ‰‡ ‰‡‰Â ÓÚ„Ó‚Ó ̇ ‚˙ÔÓÒ‡ Í‡Í ÌÓ‚ÓÒÚËÚ ‚ Á‰‡‚ÂÓÔ‡Á‚‡ÌÂÚÓ ‚ÎËflflÚ ‚˙ıÛ Ó·˘ËÚ ‡ÁıÓ‰Ë (2). àÏÂÌÌÓ ˜ÂÁ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁË ÏÓÊ ‰‡ Ò ‰‡‰Â ÓÚ„Ó‚Ó ÍÓË ÓÚ Úflı ‰‡ ·˙‰‡Ú ÓÚı‚˙ÎÂÌË Ë ÍÓË - ‚˙ÁÔËÂÚË ‚ Θ·ÌËfl ÔÓˆÂÒ, Ú˙È Í‡ÚÓ ÓÒË„Ûfl‚‡Ú ÔÓÎÁË ‚ Á‡Ïfl̇ ̇ ‚ÎÓÊÂÌËÚ Ò‰ÒÚ‚‡. àÌÙÓχÚ˂̇ڇ ÒÚÓÈÌÓÒÚ Ì‡ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËÚ ÔÓÛ˜‚‡ÌËfl ‚Ë̇„Ë Ò ӈÂÌfl‚‡ Ò˙Ó·‡ÁÌÓ ÒËÒÚÂχڇ ̇ Á‰‡‚ÂÓÔ‡Á‚‡ÌÂ Ë „ÂÓ„‡ÙÒÍÓÚÓ ‡ÁÔÓÎÓÊÂÌËÂ. íÓ‚‡ Ô‡‚Ë Ì‚˙ÁÏÓÊÌÓ “ÔÂı‚˙ÎflÌÂÚÓ” ̇ ÂÁÛÎÚ‡ÚËÚ ÓÚ Â‰Ì‡ ÒÚ‡Ì‡ ‚ ‰Û„‡, ͇ÍÚÓ Ë ‚ÁËχÌÂÚÓ Ì‡ ¯ÂÌËfl ‚˙Á ÓÒÌÓ‚‡ ̇ Úflı. (3) á‰‡‚̇ڇ ËÍÓÌÓÏË͇  ‰ËÒˆËÔÎË̇, Ò˙Ò‰ÓÚÓ˜Â̇ ‚ Ú˙ÒÂÌÂÚÓ Ì‡ ÓÚ„Ó‚ÓËÚ ̇ ÌflÍÓÎÍÓ ‚‡ÊÌË ‚˙ÔÓÒ‡ ‚ ӷ·ÒÚÚ‡ ̇ Á‰‡‚ÂÓÔ‡Á‚‡ÌÂÚÓ: ● ä‡Í ‰‡ ·˙‰‡Ú ÔÓÒÂ˘Ì‡ÚË ÔÓÒÚÓflÌÌÓ Ì‡‡ÒÚ‚‡˘ËÚ ‡ÁıÓ‰Ë ‚ Ú‡ÁË Ó·Î‡ÒÚ ÔË Ó„‡Ì˘ÂÌËÚ ‡ÁÏÂË Ì‡ Á‰‡‚ÌËfl ·˛‰ÊÂÚ? ● ä‡Í ‰‡ ·˙‰Â ÓÒË„ÛÂÌÓ Ï‡ÍÒËχÎÌÓ ‰Ó·Ó Á‰‡‚ÌÓ Ó·ÒÎÛÊ‚‡ÌÂ, ̇ ‚˙ÁÏÓÊÌÓ Ì‡È-„ÓÎflÏ ·ÓÈ ıÓ‡ ÔË Ó„‡Ì˘ÂÌÓ ÍÓ΢ÂÒÚ‚Ó Ò‰ÒÚ‚‡? ● ä‡Í ‰‡ Ó„‡ÌËÁË‡Ï Ôӂ‰ÂÌËÂÚÓ Ì‡ ‡Á΢ÌËÚ Á‚Â̇ ‚ ÒÚÛÍÚÛ‡Ú‡ ̇ Á‰‡‚̇ڇ ÒËÒÚÂχ, ڇ͇ ˜Â Á‡ ‚ÒÂÍË Ô‡ˆËÂÌÚ ‰‡ ·˙‰Â ̇Á̇˜ÂÌÓ Î˜ÂÌËÂÚÓ, ÍÓÂÚÓ Ì ҇ÏÓ ‰‡ ‰Ó‚‰ ‰Ó ̇È-ÛÒÔ¯ÌÓÚÓ ÏÛ ËÁÎÂÍÛ‚‡ÌÂ, ÌÓ Ë ‰‡ ÓÒË„ÛË Ï‡ÍÒËχÎÌË Î˘ÌË, ÔÓÙÂÒËÓ̇ÎÌË Ë ÒӈˇÎÌË ÔÓÎÁË?(4) èË ‡Á„ÎÂʉ‡ÌÂÚÓ Ì‡ ÔÓ·ÎÂχ Á‡ Á‰‡‚ÂÚÓ Ì‡ Ô‡ˆËÂÌÚ‡, ‚˙ÔÓÒ˙Ú Á‡ ˆÂ̇ڇ Ì Úfl·‚‡ ‰‡ ·˙‰Â ‡Á„ÎÂʉ‡Ì Ò Ô‰ËÏÒÚ‚Ó. íÓ‚‡  ÓÒÓ·ÂÌÓ ‚flÌÓ Á‡ Θ·ÌËÚ ¯ÂÌËfl, Á‡ ÍÓËÚÓ ÎËÔÒ‚‡ ‰Û„‡ ‡ÎÚÂ̇ÚË‚‡. Ç ÚÓÁË ÒÎÛ˜‡È ‡ÁıÓ‰ËÚ ÍÓÎÍÓÚÓ Ë „ÓÎÂÏË ‰‡ Ò‡ ÚÂ, Ì ·Ë Úfl·‚‡ÎÓ ‰‡ Ò‡ ÓÔ‰ÂÎfl˘ Ù‡ÍÚÓ ‚ Ôӂ‰ÂÌËÂÚÓ Ì‡ ÓÚ„Ó‚ÓÌËÚ Ó„‡ÌË, ÒÚË„‡ ÔÓÎÛ˜ÂÌÓÚÓ Î˜ÂÌË ‰‡ Â Ò ‰ÓÒÚ‡Ú˙˜Ì‡ ÂÙÂÍÚË‚ÌÓÒÚ. èË Á‡·ÓÎfl‚‡ÌËfl Í˙‰ÂÚÓ Ëχ ‡Á΢ÌË ÚÂ‡Ô‚Ú˘ÌË ‡ÎÚÂ̇ÚË‚Ë, ‚Òfl͇ ÓÚ ÍÓflÚÓ Ô‰·„‡ ̇·Ó ÓÚ ÔÓÎÓÊËÚÂÎÌË ÍÎËÌ˘ÌË ËÁıÓ‰Ë Ë ı‡‡ÍÚÂÌË Ò‚˙Á‡ÌË Ò ÌÂfl ÌÂÊ·ÌË Ò˙·ËÚËfl Ë ‡ÁıÓ‰Ë,  ÌÂÓ·ıÓ‰ËÏÓ ‰‡ Ò ÔËÎÓ-

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Ê‡Ú Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁË Á‡ ËÁ·Ë‡ÌÂÚÓ Ì‡ ̇È-‡‰ÂÍ‚‡Ú̇ڇ ÚÂ‡ÔËfl. êÓÎflÚ‡ ̇ ÎÂÍÛ‚‡˘Ëfl ÎÂ͇  ‰ËÌÒÚ‚ÂÌÓ ‰‡ ÔÓ‰·ÂÂ Ë ÔËÎÓÊË Ì‡È-ÂÙÂÍÚË‚ÌÓÚÓ Î˜ÂÌË Á‡ ‰‡‰ÂÌËfl Ô‡ˆËÂÌÚ. Ç ÍÎËÌ˘̇ڇ Ô‡ÍÚË͇ Ò˙Ó·‡Áfl‚‡ÌÂÚÓ Ò Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËÚ ‰‡ÌÌË Â ÚÛ‰ÌÓ ÓÒ˙˘ÂÒÚ‚ËÏÓ. ê¯ÂÌËÂÚÓ ‚ÁÂÚÓ Ì‡ ÍÎËÌ˘ÌÓ ÌË‚Ó Ì ·Ë‚‡ ‰‡ ·˙‰Â ÔÓ‚ÎËflÌÓ ÓÚ ËÍÓÌÓÏ˘ÂÒÍËÚ ÔÓÒÎÂ‰ËˆË ÓÚ Ì‡Á̇˜‡‚‡ÌÂÚÓ Ì‡ ‰ÌÓ ËÎË ‰Û„Ó Î˜ÂÌËÂ. êÓÎflÚ‡ ̇ ÍÓÌÚÓÎÌËÚ Ó„‡ÌË ‚ ÚÓÁË ÔÓˆÂÒ Â ‚˙Á ÓÒÌÓ‚‡ ̇ Ò˙·‡ÌË Ó·ÂÍÚË‚ÌË ‰‡ÌÌË, ‰‡ ËÁ„‡‰flÚ „ËÓ̇Î̇ ËÎË ‰˙ʇ‚̇ ÔÓÎËÚË͇, ÍÓflÚÓ ‰‡ ÓÒË„Ûfl‚‡ ̇ ωˈËÌÒÍËfl ÒÔˆˇÎËÒÚ ‰ÓÒÚ‡Ú˙˜ÌÓ Ì‡ ·ÓÈ ÂÙÂÍÚË‚ÌË ÚÂ‡Ô‚Ú˘ÌË ‡ÎÚÂ̇ÚË‚Ë (ËÁ„‡Ê‰‡Ì ̇ ÒÔËÒ˙Í Ò ÂÒÂ̈ˇÎÌË ÎÂ͇ÒÚ‚‡). èÓ Ú‡Í˙‚ ̇˜ËÌ ‚ ÍÎËÌ˘̇ڇ Ô‡ÍÚË͇ Ì ·Ë Úfl·‚‡ÎÓ ‰‡ Ò˙˘ÂÒÚ‚Û‚‡Ú ÚÂ‡Ô‚Ú˘ÌË ‡ÎÚÂ̇ÚË‚Ë Ò˙Ò Á̇˜ËÏË ‡ÁÎËÍË ‚ Ô‡‡ÏÂÚËÚ ̇ ˆÂ̇/ÂÙÂÍÚË‚ÌÓÒÚ ËÎË ˆÂ̇/ÔÓÎÂÁÌÓÒÚ. èË Ó·Ò˙ʉ‡Ì ̇ ‡ÁıÓ‰Ë Ë ÔÓÎÁË, Ì ‚Ë̇„Ë „Ó‚ÓËÏ Á‡ ÔÂÍËÚ ÏÓÌÂÚ‡ÌË ËÁÏÂÂÌËfl ̇ Í‡ÈÌËÚ ÂÁÛÎÚ‡ÚË ÓÚ Î˜ÂÌËÂÚÓ. í‡Í‡ ̇ÔËÏÂ ‚‡ÊÂÌ ‡ÒÔÂÍÚ Ì‡ ÔÓ·ÎÂÏËÚ ÔË ÂÔËÎÂÔÚ˘ÌÓ ·ÓÎÌËÚ Ô‰ÒÚ‡‚Îfl‚‡ Ù‡ÍÚ˙Ú, ˜Â ÂÔËÎÂÔÒËflÚ‡  Á‡·ÓÎfl‚‡Ì ı‡‡ÍÚÂËÁË‡˘Ó ÒÂ Ò ÍÎËÌ˘̇ ÌÂÒË„ÛÌÓÒÚ, ÔËÚÂÒÌÂÌËfl Ë Ú‚ӄË. íÓ‚‡ ‚ Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë ÌÓÒË Î˘ÌÓÒÚ̇, ÔÓÙÂÒËÓ̇Î̇ Ë ÒӈˇÎ̇ ÒÚ˄χ Á‡ Ô‡ˆËÂÌÚ‡ (5). ñÂÎÚ‡ ̇ ‡ÌÚËÂÔËÎÂÔÚ˘ÌÓÚÓ Î˜ÂÌË  Ì ҇ÏÓ ÔÂχı‚‡ÌÂÚÓ Ì‡ ÔËÒÚ˙ÔËÚÂ, ÌÓ Ë Ô˙ÎÌÓÚÓ ÔÓÙÂÒËÓ̇ÎÌÓ Ë ÒӈˇÎÌÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ô‡ˆËÂÌÚ‡. (1). ëΉӂ‡ÚÂÎÌÓ Á‡ ‰‡ ·˙‰Â ̇ËÒÚË̇ ÂÙÂÍÚË‚ÌÓ Â‰ÌÓ Î˜ÂÌË ·Ë Úfl·‚‡ÎÓ Ì ҇ÏÓ ‰‡ ÔÓ‚ÎËfl ÒËÏÔÚÓÏËÚ ÔË ÏËÌËχÎÌË ‡ÁıÓ‰Ë, ÌÓ Ë ‰‡ ÓÒË„ÛË Ï‡ÍÒËχÎÌÓ ‰Ó·Ó Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ. èÓ Ú‡ÁË Ô˘Ë̇ ÓˆÂÌ͇ڇ ̇ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ, Ô‰ÓÒÚ‡‚Â̇ ÓÚ „Ή̇ڇ ÚӘ͇ ̇ ·ÓÎÌËfl, Ë„‡Â ÓÒÌӂ̇ ÓÎfl ÔË ÓÚ˜ËÚ‡ÌÂÚÓ Ì‡ ÔÓÎÁËÚ ÓÚ Î˜ÂÌËÂÚÓ. î‡χÍÓËÍÓÌÓÏË͇ڇ  ‰̇ Ò‡‚ÌËÚÂÎÌÓ ÌÓ‚‡ ÒÔˆˇÎÌÓÒÚ ˜ËËÚÓ ÏÂÚÓ‰Ë ÔÓÁ‚ÓÎfl‚‡Ú ‰‡ Ò ӈÂÌË ‡‰ÂÍ‚‡ÚÌÓÒÚÚ‡ ̇ ‰Ë‡„ÌÓÒÚ˘ÌÓÚÓ Ë ÚÂ‡Ô‚Ú˘ÌÓÚÓ Ôӂ‰ÂÌË ÓÚ ÔÓ-¯ËÓ͇ „Ή̇ ÚӘ͇. í‡Í‡ ÒÚ‡‚‡ ‚˙ÁÏÓÊÌÓ ‰‡ Ò ÔˆÂÌË Ì ҇ÏÓ ÔÂÍËfl ÂÙÂÍÚ Ì‡ ‰‡‰Â̇ ÚÂ‡ÔËfl ‚˙ıÛ Ô‡ÚÓÎÓ„ËflÚ‡, ÌÓ Ë ÔÓ-ÓÚ‰‡Î˜ÂÌËÚ ‚˙‚ ‚ÂÏÂÚÓ Ï‰ˈËÌÒÍË, ÒӈˇÎÌË, ËÍÓÌÓÏ˘ÂÒÍË Ë Î˘ÌÓÒÚÌË ÔÓÒΉˈË. íÓ‚‡ Ô‡‚Ë Ì‡ÎÓÊËÚÂÎÌË Ë ËÁÍβ˜ËÚÂÎÌÓ Á̇˜ËÏË ÔÓÛ˜‚‡ÌËflÚ‡ ‚ Ú‡ÁË Ó·Î‡ÒÚ Í‡ÍÚÓ ‚ Ò‚ÂÚÓ‚ÂÌ Ú‡Í‡ Ë ‚ ÎÓ͇ÎÂÌ Ï‡˘‡· (6). Ç ËÒÚÓ˘ÂÒÍË ÔÎ‡Ì Á‡‡Ê‰‡ÌÂÚÓ Ì‡ ˉÂflÚ‡ Á‡ Ù‡χÍÓËÍÓÌÓÏË͇ Á‡ÔÓ˜‚‡ ÔÂÁ 1960, ÍÓ„‡ÚÓ ÌflÍÓË ‡‚ÚÓË ‚˙‚Âʉ‡Ú ËÁÔÓÎÁ‚‡ÌÂÚÓ Ì‡ ËÍÓÌÓÏ˘ÂÒÍË ÏÂÚÓ‰Ë Á‡ ‡Ì‡ÎËÁ ̇ Á‰‡‚ÂÚÓ Ë Á‰‡‚ÓÒÎÓ‚ÌËÚ ÔÓ·ÎÂÏË (7, 8). èÂÁ 1978 McGhan, Rowland, and Bootman, Ò‡ Ò‰ Ô˙‚ËÚÂ, ÔÓÒÚ‡‚ËÎË ÓÒÌÓ‚ËÚ ̇ ‰‚‡ ÓÚ ÓÒÌÓ‚ÌËÚ ÏÂÚÓ‰‡ ‚ Ú‡ÁË ÌÓ‚‡ ‰ËÒˆËÔÎË̇ ‡Ì‡ÎËÁËÚ cost-benefit Ë cost-effectiveness (9). í‡Í‡ ÔÂÁ ÓÒÂωÂÒÂÚÚ „Ó‰ËÌË Ì‡ ÏË̇ÎËfl ‚ÂÍ Ò ÒÚË„‡ ‰Ó ÓÙˈˇÎÌÓÚÓ Á‡‡Ê‰‡Ì ̇ Ù‡χÍÓËÍÓÌÓÏË͇ڇ ͇ÚÓ Ì‡Û͇. èÓÒÚÂÔÂÌÌÓÚÓ Ì‡‡ÒÚ‚‡Ì ̇ ‡ÁıÓ‰ËÚ ‚ Á‰‡‚ÂÓÔ‡Á‚‡ÌÂÚÓ ·˙ÁÓ Ô‚˙˘‡ Ú‡ÁË ÌÓ‚‡ ÒÔˆˇÎÌÓÒÚ ‚ Ô‡ÍÚ˘ÂÒ͇ ‰ËÒˆËÔÎË̇ (10) ᇠÌÛʉËÚ ̇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍÓÚÓ ËÁÒΉ‚‡Ì Ò ËÁÔÓÎÁ‚‡Ú ÔÓ͇Á‡ÚÂÎË Ò ‰ÓÒÚ‡Ú˙˜Ì‡ Ó·ÂÍÚË‚ÌÓÒÚ, ÔÓ ÍÓËÚÓ ‰‡ Ò Ò˙‰Ë Á‡ ÂÙÂÍÚË‚ÌÓÒÚÚ‡ ̇ Ò‡‚Ìfl‚‡ÌËÚ ‡ÎÚÂ̇ÚË‚Ë. íÂÁË ÔÓ͇Á‡ÚÂÎË Úfl·‚‡ ‰‡ Ò‡ ÒË„ÛÌË, ÎÂÒÌË Á‡ Ó·ÂÍÚË‚ÌÓ ÓÚ˜ËÚ‡ÌÂ Ë ÍÎËÌ˘ÌÓ Á̇˜ËÏË. è‰ËÏÒÚ‚Ó Â ‡ÍÓ Ò ÓÚ˜ËÚ‡Ú Ô‡‡ÏÂÚË, ÍÓËÚÓ Ò‡ ÎÂÒÌË Á‡ ÔÓÒΉfl‚‡ÌÂ Ë Ì Ô‰ËÁ‚ËÍ‚‡Ú ‰ÓÔ˙ÎÌËÚÂÎÂÌ ‰ËÒÍÓÏÙÓÚ Á‡ Ô‡ˆËÂÌÚ‡. ç‡È- ˜ÂÒÚÓ ÚÓ‚‡ Ò‡ ÒÏ˙ÚÌÓÒÚ, ÔÓÏfl̇ ‚ ·ÓÎÂÒÚ̇ڇ ‡ÍÚË‚ÌÓÒÚ, ÔÂËÓ‰Ë ·ÂÁ ·ÓÎÍË, ÓÔ-


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

·͂‡ÌËfl, ÔËÒÚ˙ÔË. èÓ͇Á‡ÚÂÎËÚ (ÍËÚÂËËÚÂ), ÍÓËÚÓ Ò ËÁÔÓÎÁÛ‚‡Ú Á‡ ÓˆÂÌ͇ ÂÙÂÍÚË‚ÌÓÒÚÚ‡ ̇ ΘÂÌËÂÚÓ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú Í·ÒËÙˈË‡ÌË Í‡ÚÓ: è˙‚˘ÌË ËÎË Í‡ÈÌË (end points). í ̇È-ÚÓ˜ÌÓ ÓÚ‡Áfl‚‡Ú ËÒÚËÌÒ͇ڇ ÂÙÂÍÚË‚ÌÓÒÚ: 1. èÂÊË‚flÂÏÓÒÚ Ä/ é·˘‡ ÒÏ˙ÚÌÓÒÚ; Å/ ëÏ˙ÚÌÓÒÚ ÓÚ ÓÔ‰ÂÎÂÌÓ Á‡·ÓÎfl‚‡ÌÂ; 2. àÌ‚‡ÎˉÌÓÒÚ. 3. 䇘ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ ÇÚÓ˘ÌË ÍËÚÂËË (Secondary criteria). í ÓÚ‡Áfl‚‡Ú ÔÓ͇Á‡ÚÂÎË ÔflÍÓ Ò‚˙Á‡ÌË Ò Ô‡ÚÓ„ÂÌÂÁ‡Ú‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ.àÏ‡Ú ‰ÓÔ˙ÎÌËÚÂÎ̇ ËÌÙÓχÚ˂̇ ÒÚÓÈÌÓÒÚ. /ç‡ÔËÏÂ ‚ÚÓ˘ÂÌ ÔÓ͇Á‡ÚÂÎ Á‡ ÂÙÂÍÚË‚ÌÓÒÚ Ì‡ ÎÂ͇ÒÚ‚ÂÌËÚ Ò‰ÒÚ‚‡ ÔË ÂÔËÎÂÔÒËfl  ‰Ó·ÓÚÓ ÔÓ‚ÎËfl‚‡Ì ̇ ÖÖÉ Ì‡ıӉ͇ڇ/. ìÒÎÓ‚ÌË (Surrogates). í ҇ ÎÂÒÌÓ ‰ÓÒÚ˙ÔÌË Á‡ÏÂÒÚËÚÂÎË Ì‡ Í‡ÈÌËÚÂ Ë ‚ÚÓ˘ÌËÚ ÔÓ͇Á‡ÚÂÎË.í ÓÚ‡Áfl‚‡Ú ÌÂÔflÍÓ ‰ÂÈÒÚ‚ËÂÚÓ Ì‡ ÎÂ͇ÒÚ‚ÓÚÓ. ëÛÓ„‡ÚË Ò‡: 1. äÎËÌËÍÓ-··Ó‡ÚÓÌË ÔÓ͇Á‡ÚÂÎË 2. àÌÒÚÛÏÂÌÚ‡ÎÌË ËÁÒΉ‚‡ÌËfl ᇠ‰‡ ÔËÚÂʇ‚‡Ú ‰ÓÒÚÓ‚ÂÌÓÒÚ Á‡ ÓˆÂÌ͇ ̇ ÂÙÂÍÚË‚ÌÓÒÚÚ‡ ̇ ÚÂ‡ÔËflÚ‡ ÒÛÓ„‡ÚËÚ Úfl·‚‡ ‰‡ ÒÔ‡Á‚‡Ú ÒΉÌËÚ ÛÒÎÓ‚Ëfl: 1. ч ·˙‰‡Ú Ô‡ÚÓÙËÁËÓÎӄ˘ÌÓ Ò‚˙Á‡ÌË Ò ·ÓÎÂÒÚÚ‡. 2. ч ·˙‰‡Ú ÂÔˉÂÏËÓÎӄ˘ÌÓ Ò‚˙Á‡ÌË Ò Í‡ÈÌËÚ ÍËÚÂËË. 3. ч ·˙‰‡Ú ÚÂ‡Ô‚Ú˘ÌÓ Ò‚˙Á‡ÌË Ò Í‡ÈÌËÚ ÍËÚÂËË. 4. ч ·˙‰‡Ú ÔÓ-ÎÂÒÌÓ ‰ÓÒÚ˙ÔÌË. èË ÂÔËÎÂÔÚ˘ÌÓ ·ÓÎÌËÚÂ, Á‡ ˆÂÎËÚ ̇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ surrogates ÏÓ„‡Ú ‰‡ ·˙‰‡Ú: ‚ÂÏ ҂ӷӉÌÓ ÓÚ ÔËÒÚ˙ÔË Ë Ì‡Ï‡ÎÂÌË ̇ ˜ÂÒÚÓÚ‡Ú‡ ̇ ÔËÒÚ˙ÔËÚÂ. èÓÏÂÌËÚ ‚ “͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ “ ̇ Ô‡ˆËÂÌÚ‡ ÓÒË„Ûfl‚‡Ú Ë ÒÛ·ÂÍÚË‚ÌÓÚÓ ÛÒ¢‡Ì Á‡ ÂÙÂÍÚË‚ÌÓÒÚ Ì‡ ÚÂ‡ÔËflÚ‡ Ë ‰‡‚‡Ú ‰̇ ÔÓ-‰Ó·‡ Ë ÔÓ-Ô˙Î̇ „Ή̇ ÚӘ͇ ÔË ÓˆÂÌ͇ڇ ̇ ÂÙÂÍÚ‡. (11). Ç ÔÓˆÂÒ‡ ̇ ‡Á‚ËÚË ̇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËÚ ËÁÒΉ‚‡ÌËfl 䇘ÂÒÚ‚ÓÚÓ Ì‡ ÜË‚ÓÚ Â ·ËÎÓ ÓÔ‰ÂÎflÌÓ Í‡ÚÓ: ● ÂÏÓˆËÓ̇ÎÌËfl ÓÚ„Ó‚Ó ̇ Ë̉˂ˉ‡ ̇ Ì„ӂËÚ ÊËÚÂÈÒÍË Ó·ÒÚÓflÚÂÎÒÚ‚‡, (12) ● ‡ÁÎË͇ڇ ÏÂÊ‰Û Ó˜‡Í‚‡ÌËfl Ë ‡ÎÌÓÒÚÚ‡ Á‡ Ô‡ˆËÂÌÚ‡(13) ● ÒÔÓÒÓ·ÌÓÒÚÚ‡ ̇ Ë̉˂ˉ‡ ‰‡ ÔÓÒ¢‡ ÒÓ·ÒÚ‚ÂÌËÚ ÒË ÌÛʉË(14). è‰ÎÓÊÂÌÓÚÓ ÓÚ Schipper et al. (15) ÓÔ‰ÂÎÂÌË ÓÒË„Ûfl‚‡ ÔÓÎÂÁ̇ Ë ÙÛÌ͈ËÓ̇Î̇ ‰ÂÙËÌˈËfl, ÍÓflÚÓ ‚Íβ˜‚‡ ÔÂÚ ¯ËÓÍË Í‡Ú„ÓËË: ÙËÁ˘ÂÒÍÓ, ÔÓÙÂÒËÓ̇ÎÌÓ, ÔÒËıÓÎӄ˘ÂÒÍÓ, ÒӈˇÎÌÓ Ë ÒÓχÚ˘ÌÓ Ò˙ÒÚÓflÌËÂ. ÇÒ˘-

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ÍË ÒÔÓÏÂ̇ÚË ‡‚ÚÓË Í‡ÍÚÓ Ë ‰Û„Ë Ò Ò˙„·Òfl‚‡Ú, ˜Â ÓÔ‰ÂÎflÌÂÚÓ Ì‡ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ Úfl·‚‡ ‰‡ ·˙‰Â ËÁÏÂ‚‡ÂÏÓ, ÓˆÂÌflÂÏÓ ÒΉ ‚ÂÏÂ Ë ÒÛ·ÂÍÚË‚ÌÓ. ÑÛ„‡ ‚‡Ê̇ ı‡‡ÍÚÂËÒÚË͇ ̇ ÚÓÁË ÔÓˆÂÒ Úfl·‚‡ ‰‡ ·˙‰Â Ó·ı‚‡˘‡ÌÂÚÓ Ì‡ ‚Ò˘ÍË ÓÒÌÓ‚ÌË ÙÛÌ͈ËÓ̇ÎÌË Í‡Ú„Ó퇷Îˈ‡.1. éÔËÒ‡ÌË ̇ ÔÓ͇Á‡ÚÂÎË, ËÁÔÓÎÁ‚‡ÌË Á‡ ÓÒÚÓÈÌÓÒÚfl‚‡Ì ̇ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ. QALY- QUALITY-ADJUSTED LIFE-YEARS QALY  ˜ÂÒÚÓ ËÁÔÓÎÁ‚‡Ì‡ Ïfl͇, ӷ‰ËÌfl‚‡˘‡ ͇˜ÂÒÚ‚Ó Ë ÍÓ΢ÂÒÚ‚Ó ÊË‚ÓÚ. ífl Ò ËÁ˜ËÒÎfl‚‡ ˜ÂÁ ÓˆÂÌ͇ ̇ ÒÔ˜ÂÎÂÌËÚ ˜ÂÁ ÔË·„‡ÌÓÚÓ Î˜ÂÌË „Ó‰ËÌË ÊË‚ÓÚ, Ë ÔÂÔËÒ‚‡ÌÂÚÓ Ì‡ ‚Òfl͇ ÒÔ˜ÂÎÂ̇ „Ó‰Ë̇ ̇ ͇˜ÂÒÚ‚Â̇ ÓˆÂÌ͇, ÍÓflÚÓ ‰‡ ÓÚ‡ÁË Í‡˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ‡ ̇ Ô‡ˆËÂÌÚ‡ ÔÂÁ Ú‡ÁË „Ó‰Ë̇. ç‡ÔËÏÂ – Ô‡ˆËÂÌÚ ÊË‚flÎ 10 „Ó‰ËÌË Ò Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ 0.7 (Í˙‰ÂÚÓ 0  ÒÏ˙Ú, ‡ 1 –Ò˙ÒÚÓflÌË ̇ ÔÂÙÂÍÚÌÓ Á‰‡‚Â), ÓÒË„Ûfl‚‡ 7 QALY. DALY – DISABILITY-ADJUSTED LIFE-YEARS DALY -  ‰Û„ ÔÓ͇Á‡ÚÂÎ, ÔÓ‰Ó·ÂÌ Ì‡ QALY, ÍÓÈÚÓ Â ‡Á‡·ÓÚÂÌ ÓÚ ë‚ÂÚӂ̇ڇ ŇÌ͇ Ë ë‚ÂÚӂ̇ڇ Á‰‡‚̇ Ó„‡ÌËÁ‡ˆËfl, Á‡ ÓˆÂÌfl‚‡Ì ̇ ˆflÎÓÒÚ̇ڇ ÚÂÊÂÒÚ Ì‡ Á‡·ÓÎfl‚‡ÌËflÚ‡. èÓ‰Ó·ÌÓ Ì‡ QALY ÚÓÈ Ò˙˘Ó ӷ‰ËÌfl‚‡ ÍÓ΢ÂÒÚ‚Â̇ Ë Í‡˜ÂÒÚ‚Â̇ ÓˆÂÌ͇ ̇ Á‰‡‚ÂÚÓ. éÒÌӂ̇ڇ ‡ÁÎË͇ Â, ˜Â ÚÓÈ ËÁÏÂ‚‡ Á‡„Û·ËÚ ̇ „Ó‰ËÌË Í‡˜ÂÒÚ‚ÂÌ ÊË‚ÓÚ, ‡ Ì ÒÔ˜ÂÎÂÌËÚ ڇÍË‚‡. HYE – HEALTHY YEAR EQUIVALENTS HYE Ò˙˘Ó ÓÒË„Ûfl‚‡Ú Ïfl͇ Á‡ ÍÓ΢ÂÒÚ‚Ó Ë Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ‡. ÑÓ͇ÚÓ QALY ÔˆÂÌfl‚‡ ‚Òfl͇ ÔÂÊË‚fl̇ „Ó‰Ë̇ ҇χ Á‡ Ò· ÒË, HYE ÓÚ‡Áfl‚‡ ÔÓ‰ˈ‡ ÓÚ Á‰‡‚ÓÒÎÓ‚ÌË Ò˙ÒÚÓflÌËfl ‚˙‚ ‚ÂÏÂÚÓ Ë Á‡‰‡‚‡ ‚˙ÔÓÒ‡ : ç‡ ÍÓÎÍÓ „Ó‰ËÌË ÊË‚ÓÚ ‚ Ô˙ÎÌÓ Á‰‡‚ Ò ‡‚Ìfl‚‡Ú ÚÂ? HYE Ì Ò ËÁÔÓÎÁ‚‡Ú ˜ÂÒÚÓ ÔÓ‡‰Ë ÚÛ‰ÌÓÒÚÚ‡ ‚ ÚflıÌÓÚÓ ËÁÏÂ‚‡ÌÂ. ËË. (5, 16, 17). ïÓÌ˘ÌËflÚ ıÓ‰ ̇ ÂÔËÎÂÔÒËflÚ‡, ı‡‡ÍÚÂÓ‚ËÚ ÔÓÏÂÌË Ò‚˙Á‡ÌË Ò ÔÓÚ˘‡ÌÂÚÓ Ë Î˜ÂÌËÂÚÓ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ, ÌÂÊ·ÌËÚ ‡͈ËË Ë ÒӈˇÎ̇ڇ ÒÚ˄χ, Ô‡‚flÚ ÓˆÂÌ͇ڇ ̇ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ ÓÚ Ô˙‚ÓÒÚÂÔÂÌ̇ Á̇˜ËÏÓÒÚ ÔË Î˜ÂÌËÂÚÓ Ì‡ Ô‡ˆËÂÌÚ Ò ÂÔËÎÂÔÒËfl. èÓ Ú‡ÁË Ô˘Ë̇ ‚Ò Ôӂ˜ هχÍÓËÍÓÌÓÏ˘ÂÒÍË ÔÓÛ˜‚‡ÌËfl ‚ Ú‡ÁË Ó·Î‡ÒÚ, ‚Íβ˜‚‡Ú ÚÓÁË ÔÓ͇Á‡ÚÂÎ ‚ ËÁÒΉ‚‡ÌËÚ ԇ‡ÏÂÚË. éÚ˜ËÚ‡ÌÂÚÓ Ì‡ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ ÒÚ‡‚‡ Ò ÔÓÏÓ˘Ú‡ ̇ ÔÓ͇Á‡ÚÂÎË Í‡ÚÓ QALY, DALY, HYE (Ú‡·Îˈ‡.1.) ËÁ·Ë‡ÌË ÒÔÓ‰ ı‡‡ÍÚÂËÒÚËÍËÚ ̇ ÓÚ‰ÂÎÌËÚ ÔÓÛ˜‚‡ÌËfl Ë Ú˙ÒÂÌËÚ Í‡ÈÌË ÂÁÛÎÚ‡ÚË (4). ᇠÓÒÌÓ‚‡ ̇ Ò˙Á‰‡‚‡ÌÂÚÓ Ì‡ Ô‡‚ËÎÌÓ ÚÂ‡Ô‚Ú˘ÌÓ Ôӂ‰ÂÌË ̇ „ËÓ̇ÎÌÓ ËÎË ËÌÒÚËÚÛˆËÓ̇ÎÌÓ ÌË‚Ó, ·Ë Úfl·‚‡ÎÓ ‰‡ ÒÎÛÊ‡Ú Â‰ËÌÒÚ‚ÂÌÓ ÍÓÂÍÚÌÓ Ôӂ‰ÂÌË Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ÔÓÛ˜‚‡ÌËfl. Ç Ì‡¯‡Ú‡ ÒÚ‡Ì‡ ̇ۘÌË ÚÛ‰Ó‚Â ‚ ӷ·ÒÚÚ‡ ̇ Ù‡χÍÓËÍÓÌÓÏË͇ڇ Ò‡ ‡Á‡·ÓÚ‚‡ÌË ÔÓ ÓÚÌÓ¯ÂÌË ̇ ‡ÌÚË·‡ÍÚÂˇÎÌÓÚÓ Î˜ÂÌË ̇ ÔÌ‚ÏÓÌËËÚÂ(18), ΘÂÌË ̇ ‡ÚÂˇÎ̇ ıËÔÂÚÓÌËfl Ò ÄëÖ ËÌıË·ËÚÓË (19), ıÓÌ˘ÂÌ ıÂÔ‡ÚËÚ ë (20),

퇷Îˈ‡ .2. Çˉӂ هχÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ Çˉ ‡Ì‡ÎËÁ Cost – effectiveness

ÇıÓ‰ÌË ‰‡ÌÌË ê‡ÁıÓ‰Ë

àÁıÓ‰ÌË ‰‡ÌÌË ÅÓÈ ÛÒÔ¯ÌÓ ËÁÎÂÍÛ‚‡ÌË, ÒÔ˜ÂÎÂÌË „Ó‰ËÌË ÊË‚ÓÚ, Ò‚Ó·Ó‰ÂÌ ÓÚ ·ÓÎÂÒÚ ÔÂËÓ‰ ç Ò ÔÓÎÛ˜‡‚‡Ú ‚ ‡ÏÍËÚ ̇ Ò‡ÏÓÚÓ ËÁÒΉ‚‡ÌÂ

Cost – minimization

ê‡ÁıÓ‰Ë (̇È-˜ÂÒÚÓ Ò‡ÏÓ ‰ËÂÍÚÌË)

Cost – utility

ê‡ÁıÓ‰Ë

Quality Adjusted Life Years (QALY) – ÂÍ‚Ë‚‡ÎÂÌÚÌË „Ó‰ËÌË ‚ Ô˙ÎÌÓ Á‰‡‚Â

Cost –benefit

ê‡ÁıÓ‰Ë

åÓÌÂÚ‡ÌÓ ËÁ‡Áfl‚‡Ì ̇ ÔÓÎÁ‡Ú‡

àÌÚÂÔÂÚ‡ˆËfl ë‡‚Ìfl‚‡Ì ̇ ÂÁÛÎÚ‡ÚËÚ ÓÚ ‡ÎÚÂ̇ÚË‚ÌÓ ÚÂ‡Ô‚Ú˘ÌÓ Ôӂ‰ÂÌË í˙ÒÂÌ ̇ ̇È- ÌËÒÍËflÚ ‡ÁıÓ‰ ‚Ӊ¢ ‰Ó ÚÓ˜ÌÓ ÓÔ‰ÂÎÂÌ ÂÁÛÎÚ‡Ú ê‡ÁıÓ‰ Á‡ QALY ÔË ‡Á΢ÌË Ô˙‚Ó̇˜‡ÎÌÓ ÔÓ ÂÙÂÍÚË‚ÌÓÒÚ ‡ÎÚÂ̇ÚË‚Ë ë˙ÓÚÌÓ¯ÂÌË ˆÂ̇-ÔÓÎÁ‡


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ıÂÔ‡ÚËÚ Ä, Ç Ë ë (21), ·ÓÌıˇÎ̇ ‡ÒÚχ (22), ÌÓ ‚Ò Ӣ ÎËÔÒ‚‡ ‡Ì‡ÎËÁ ÓÚ Í‡Í˙‚ÚÓ Ë ‰‡  ÚËÔ ‚ ӷ·ÒÚÚ‡ ̇ Ì‚ÓÎÓ„ËflÚ‡ ËÎË ÂÔËÎÂÔÒËflÚ‡. ë˙˘ÂÒÚ‚Û‚‡Ú ˜ÂÚËË ÓÒÌÓ‚ÌË ÚËÔ‡ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ- Cost – effectiveness, Cost – minimization, Cost – utility, Cost –benefit ‡Ì‡ÎËÁ, ͇ÍÚÓ Ë ÌflÍÓÎÍÓ „ΉÌË ÚÓ˜ÍË, ÓÚ ÍÓËÚÓ ‰‡ ·˙‰Â Ôӂ‰ÂÌ. ê‡Á΢ÌËÚ ‚ˉӂ ‡Ì‡ÎËÁ Ò ‡Á΢‡‚‡Ú ÔÓ ÓÚÌÓ¯ÂÌË ̇ ‚ıÓ‰ÌËÚ ‰‡ÌÌË, ÍÓËÚÓ ÓÚ˜ËÚ‡Ú Ë ÔÓ ÔÓÎÛ˜ÂÌËÚ ÂÁÛÎÚ‡ÚË. (퇷Îˈ‡.2.) èË Cost – effectiveness ‡Ì‡ÎËÁ˙Ú Ò Ò˙ÔÓÒÚ‡‚fl ËÁÏÂ‚‡ÌÂÚÓ Ì‡ ˜ËÒÚËÚ ‡ÁıÓ‰Ë ÔË ÓÔ‰ÂÎÂÌÓ Î˜ÂÌËÂ Ë ÔÓÒÚ˄̇ÚËfl Í‡ÂÌ ÂÁÛÎÚ‡Ú. èÓÒΉÌËflÚ Ò ËÁ‡Áfl‚‡ ‚ flÒÌÓ ÓÔ‰ÂÎÂÌ ÍÎËÌ˘ÂÌ ËÁıÓ‰ – ̇Ô. ÒÔ˜ÂÎÂÌË „Ó‰ËÌË ÊË‚ÓÚ, ËÎË ‚ ÒÎÛ˜‡È ˜Â  ‰Ó͇Á‡Ì‡ flÒ̇ ‚˙Á͇ Ò ÌÂ„Ó – ‰ÓÒÚÓ‚Â̇ ÔÓÏfl̇ ̇ ‰‡‰ÂÌ ÍÎËÌ˘ÂÌ ÔÓ͇Á‡ÚÂÎ. íÓÁË ÚËÔ ‡Ì‡ÎËÁ  ÔÓ‰ıÓ‰fl˘ Á‡ Ò‡‚Ìfl‚‡Ì ̇ ‡ÎÚÂ̇ÚË‚Ë,

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˜‡Ú ÔÓÎÁËÚ ÓÚ ‰‡‰ÂÌÓ Î˜ÂÌË ËÎË ‰‡ ËÁ·Â„Ì‡Ú ‡ÁıÓ‰ËÚ ÓÚ ‡Á‚ËÚËÂÚÓ Ì‡ ·ÓÎÂÒÚÚ‡. è‡‚ËÎÌËflÚ ËÁ·Ó ÏÂÊ‰Û ‚ˉӂÂÚ هχÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ - Cost – effectiveness, Cost – minimization, Cost – utility, Cost –benefit – Ò ÓÒÌÓ‚‡‚‡ ̇ ÔÓÒÚ‡‚ÂÌËÚ ˆÂÎË Ë Ú˙ÒÂÌËÚ ÍÎËÌ˘ÌË ÂÁÛÎÚ‡ÚË. ë˙˘ÂÒÚ‚Û‚‡Ú ÓÒÌÓ‚ÌË ÏÓÏÂÌÚË ‚ ÔÓ‚Âʉ‡ÌÂÚÓ Ì‡ ‚ÒÂÍË Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ, Á‡ ‰‡ ·˙‰Â ÚÓÈ ÍÓÂÍÚÌÓ Ôӂ‰ÂÌ Ë ‰ÓÒÚÓ‚ÂÂÌ: ● ÑÂÙËÌË‡Ì ̇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËfl ÔÓ·ÎÂÏ – ÓÚ„Ó‚Ó˙Ú Ì‡ ÍÓÈ ‚˙ÔÓÒ Ò Ú˙ÒË Ë Á‡˘Ó? ● éÔ‰ÂÎflÌÂÚÓ Ì‡ ÔÂÒÔÂÍÚË‚‡Ú‡, ÓÚ ÍÓflÚÓ Ò ÔÓ‚Âʉ‡ ‡Ì‡ÎËÁ˙Ú –Ô‡ˆËÂÌÚ, Ô·Úˆ, Ó·˘ÂÒÚ‚Ó. ● àÁ·Ó ̇ ËÁÒΉ‚‡ÌËÚ ÚÂ‡Ô‚Ú˘ÌË ‡ÎÚÂ̇ÚË‚Ë Ë Úflı̇ڇ ÓˆÂÌ͇. ● àÁ·Ó ̇ ÔÓ‰ıÓ‰fl˘ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ÏÂÚÓ‰,

퇷Îˈ‡ .3. Çˉӂ ‡ÁıÓ‰Ë ‚˙‚ Ù‡χÍÓËÍÓÌÓÏË͇ڇ Çˉ ‡ÁıÓ‰Ë Direct costs – ·Ë‚‡Ú ωˈËÌÒÍË Ë ÌÂωˈËÌÒÍË

éÔËÒ‡ÌË èÂÍËÚ ‡ÁıÓ‰Ë ÔÓ ·ÓÎÂÒÚÚÚ‡ Ë Î˜ÂÌËÂÚÓ, ÍÓËÚÓ Ò Ô‡‚flÚ ‚ ωˈËÌÒÍËfl ÒÂÍÚÓ

Indirect costs

ê‡ÁıÓ‰ËÚ ҂˙Á‡ÌË Ò˙Ò Á‡„Û·‡Ú‡ ̇ ÔÓ‰ÛÍÚË‚ÌÓÒÚ ÔÓ‡‰Ë ΘÂÌËÂÚÓ, ·ÓÎÂÒÚÚ‡ ËÎË ÌÛʉ‡Ú‡ Á‡ „ËÊË Ì‡ ·ÓÎÂÌ ˜ÎÂÌ Ì‡ ÒÂÏÂÈÒÚ‚ÓÚÓ çÂËÁÏÂËÏËÚ Á‡„Û·Ë ÓÚ ÒÚ‡Ì‡ ̇ Ô‡ˆËÂÌÚ‡ ÔÓ‡‰Ë ÒÚ‡‰‡ÌËÂÚÓ ËÎË ·ÓÎ͇ڇ ÓÚ ·ÓÎÂÒÚÚ‡ ËÎË ÒÚ‡Ì˘ÌËÚ ÂÙÂÍÚË Ì‡ ΘÂÌËÂÚÓ

Intangible costs

ÍÓËÚÓ ÓÒË„Ûfl‚‡Ú ËÁÏÂËÏË ÍÎËÌ˘ÌË ÂÁÛÎÚ‡ÚË, ڇ͇ ˜Â ‰‡ ·˙‰Â ÔÓ‰·‡Ì‡ Ú‡ÁË Ò ÔÓ-‰Ó·Ó Ò˙ÓÚÌÓ¯ÂÌË “‡ÁıÓ‰/ÂÙÂÍÚ”. èË Cost – minimization ‡Ì‡ÎËÁ˙Ú Ò Ò‡‚Ìfl‚‡Ú ÚÂ‡Ô‚Ú˘ÌË ‡ÎÚÂ̇ÚË‚Ë, Á‡ ÍÓËÚÓ Ò ÒÏflÚ‡, ˜Â ‰‡‚‡Ú ͇ÚÓ ÂÁÛÎÚ‡Ú ÔÓ‰Ó·ÌË ËÎË Â‰Ì‡Í‚Ë ÍÎËÌ˘ÌË ËÁıÓ‰Ë (̇ÔËÏÂ ‰‚‡ ÏÂÚÓ‰‡ Á‡ ıËÛ„˘̇ ̇ÏÂÒ‡ Ò Í‡ÂÌ ÂÁÛÎÚ‡Ú – ıËÒÚÂÂÍÚÓÏËfl, Ò‡‚Ìfl‚‡Ì ̇ ÓË„Ë̇ÎÂÌ ÔÂÔ‡‡Ú Ò Ì„ӂËfl „ÂÌÂ˘ÂÌ ÂÍ‚Ë‚‡ÎÂÌÚ Ë Ú.Ì.). Ç ÚÓÁË ÒÎÛ˜‡È ‚Ó‰Â˘Ó Á̇˜ÂÌË Á‡ ËÁ·Ó˙Ú Ì‡ ‰‡‰Â̇ ‡ÎÚÂ̇ÚË‚‡ ËÏ‡Ú Ì‡Ô‡‚ÂÌËÚ ‡ÁıÓ‰Ë ÔË Î˜ÂÌËÂÚÓ, Ú˙È Í‡ÚÓ Ì Ò Ò‡‚Ìfl‚‡Ú ÂÁÛÎÚ‡ÚËÚÂ, ‡ Ò‡ÏÓ ËÁ‡ÁıÓ‰‚‡ÌËÚ ÂÒÛÒË. èË Cost – utility ‡Ì‡ÎËÁ˙Ú ÔÓÎÁËÚ Ò ËÁÏÂ‚‡Ú ‚ „Ó‰ËÌË Á‰‡‚ ÊË‚ÓÚ, Í˙Ï ÍÓËÚÓ Â ÔËÍÂÔÂ̇ ÒÚÓÈÌÓÒÚ Ú.Â. ÍÓÎÍÓ ·Ë ÒÚÛ‚‡ÎÓ ‰‡ Ò ÓÒË„ÛË Ú‡Í‡‚‡ „Ó‰Ë̇ ÊË‚ÓÚ Ì‡ ‰‡‰ÂÌËÚ ԇˆËÂÌÚË ÔË ËÁ·Ó˙Ú Ì‡ ‰̇ ËÎË ‰Û„‡ ‡ÎÚÂ̇ÚË‚‡. Cost–benefit ‡Ì‡ÎËÁ˙Ú ËÁ‡Áfl‚‡ ÔÓÎÁËÚ ‚ ÏÓÌÂÚ‡ÌË Â‰ËÌˈË. ä‡ÈÌËflÚ ÂÁÛÎÚ‡Ú Â Á‡„Û·Â̇ڇ ËÎË ÒÔ˜ÂÎÂ̇ ÒÛχ ËÎË Ò˙ÓÚÌÓ¯ÂÌËÂÚÓ ÏÂÊ‰Û ËÁ‡ÁıÓ‰‚‡ÌËÚ ÒÛÏË Ë „ÂÌÂË‡ÌËÚ ڇÍË‚‡. íÓÁË ‡Ì‡ÎËÁ Ò ËÁ‚˙¯‚‡ ÔÓ ‰‚‡ ÓÒÌÓ‚ÌË ÏÂÚÓ‰‡ – ÔÓ‰ıÓ‰˙Ú “˜Ó‚¯ÍË Í‡ÔËڇΔ ËÎË ÔÓ‰ıÓ‰˙Ú “„ÓÚÓ‚ÌÓÒÚ Á‡ Ô·˘‡Ì” (4). èÓ‰ıÓ‰˙Ú “˜Ó‚¯ÍË Í‡ÔËڇΔ ÔÓ͇Á‚‡ ÔÓ‰Ó·ÂÌËÂÚÓ ‚ Á‰‡‚ÂÚÓ Ì‡ ÓÒÌÓ‚‡ ̇ ·˙‰Â˘‡Ú‡ ÔÓ‰ÛÍÚË‚ÌÓÒÚ Á‡ Ó·˘ÂÒÚ‚ÓÚÓ Ì‡ ËÁÎÂÍÛ‚‡ÌËfl Ë̉˂ˉ, ÍÓÈÚÓ Â ÒÔÓÒÓ·ÂÌ ‰‡ Ò Á‡‚˙Ì Í˙Ï ÔÓÙÂÒËÓ̇ÎÌËfl ÒË ÊË‚ÓÚ. åÂÚÓ‰˙Ú “„ÓÚÓ‚ÌÓÒÚ Á‡ Ô·˘‡Ì” Ò ÓÒÌÓ‚‡‚‡ ̇ ˉÂflÚ‡ ‰‡ ·˙‰‡Ú ËÌÚÂ‚˛Ë‡ÌË Ô‡ˆËÂÌÚËÚÂ, Á‡ ÚÓ‚‡ ÍÓÎÍÓ Ò‡ ÒÍÎÓÌÌË ‰‡ Á‡Ô·ÚflÚ, Á‡ ‰‡ ÔÓÎÛ-

èËÏÂË ● å‰ˈËÌÒÍË: ● ïÓÒÔËÚ‡ÎËÁ‡ˆËfl ● ê‡ÁıÓ‰Ë Á‡ ÒÔˆˇÎËÁË‡Ì ÔÂÒÓ̇Π● ê‡ÁıÓ‰Ë Á‡ ÎÂ͇ÒÚ‚‡ ● ê‡ÁıÓ‰Ë Á‡ ··Ó‡ÚÓÌË ËÁÒΉ‚‡ÌËfl Ë Ôӈ‰ÛË ● çÂωˈËÌÒÍË: ● ê‡ÁıÓ‰Ë Á‡ Ú‡ÌÒÔÓÚ Ë ‰ÓÔ˙ÎÌËÚÂÎÌË ÌÛÊ‰Ë Ì‡ Ô‡ˆËÂÌÚ‡ ● èÂÍË ‡ÁıÓ‰Ë Ì‡ Ô‡ˆËÂÌÚ‡, Ò‚˙Á‡ÌË Ò˙Ò Á‡·ÓÎfl‚‡ÌÂÚÓ ● á‡„Û·Ë ÔÓ‡‰Ë ÓÚÔÛÒÍ ÔÓ ·ÓÎÂÒÚ ● á‡„Û·Ë ÔÓ‡‰Ë ‡ÌÌÓ ÔÂÌÒËÓÌË‡Ì ● á‡„Û·Ë ÔÓ‡‰Ë ÌÛʉ‡ ÓÚ ÔÂÍ‚‡ÎËÙË͇ˆËfl

Á‡‚ËÒ¢ ÓÚ ÙÓχڇ ̇ Ó˜‡Í‚‡ÌËÚ ÔÓÎÁË. éÒÚÓÈÌÓÒÚfl‚‡Ì ̇ ÂÁÛÎÚ‡ÚËÚÂ Ë ÔÓÎÁËÚ ‚ ÔÓ‰ıÓ‰fl˘‡ ‚‡ÎÛÚ̇ ‰ËÌˈ‡. ● éÔ‰ÂÎflÌ ̇ ÏÂÚÓ‰ËÚ Á‡ „ËÒÚË‡Ì ̇ ÂÁÛÎÚ‡Ú‡ ÓÚ ÔËÎÓÊÂ̇ڇ ÚÂ‡Ô‚Ú˘̇ ‡ÎÚÂ̇ÚË‚‡. ● àÁ„‡Ê‰‡Ì ̇ decision tree – Ò˙Á‰‡‚‡Ì ̇ ÏÓ‰ÂΠ̇ ‚˙ÁÏÓÊÌËÚ ËÁıÓ‰Ë ÓÚ ÔË·„‡ÌÂÚÓ Ì‡ ËÁÒΉ‚‡ÌËÚ ‡ÎÚÂ̇ÚË‚Ë. ● Ä̇ÎËÁ ̇ ÂÁÛÎÚ‡ÚËÚÂ Ë ÂÍÒÚ‡ÔÓÎË‡Ì ‚˙‚ ‚ÂÏÂÚÓ ● è‰ÒÚ‡‚flÌ ̇ ÂÁÛÎÚ‡ÚËÚÂ, Ò Ó·Ò˙ʉ‡Ì ̇ Úflı̇ڇ ÍÎËÌ˘̇ ËÎË Ó·˘ÂÒÚ‚Â̇ Á̇˜ËÏÓÒÚ. (3) ᇠËÁ‚˙¯‚‡Ì ̇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ  ÌÂÓ·ıÓ‰ËÏÓ Ô‡‚ËÎÌÓ ‡ÁÔ‰ÂÎÂÌËÂ Ë ÓÚ˜Ëڇ̠̇ ‡ÁıÓ‰ËÚÂ. ê‡Á„‡Ì˘‡‚‡Ú Ò ‡Á΢ÌË ‚ˉӂ ‡ÁıÓ‰Ë ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ Ó·Î‡ÒÚÚ‡, ‚ ÍÓflÚÓ Ò ËÁ‚˙¯‚‡Ú. éÒÌÓ‚ÌËÚ ‚ˉӂ ‡ÁıÓ‰Ë ÒÔÓ‰ ӷ·ÒÚÚ‡ ‚ ÍÓflÚÓ Ò‡ ̇Ô‡‚ÂÌË ·Ë‚‡Ú Direct costs, Indirect cost, Intangible costs (Ú‡·Î. 3.) - ÔÂÍË, ÌÂÔÂÍË Ë ÌÂËÁÏÂËÏË. èÂÍËÚ ‡ÁıÓ‰Ë Ò ‡Á‰ÂÎflÚ Ì‡ ÔÂÍË Ï‰ˈËÌÒÍË Ë ÔÂÍË ÌÂωˈËÌÒÍË. èÂÍËڠωˈËÌÒÍË ‡ÁıÓ‰Ë Ò‡ ÙËÍÒË‡ÌË Ë ÔÓÏÂÌÎË‚Ë Ú‡ÍË‚‡, ÍÓËÚÓ Ò‡ ÔflÍÓ Ò‚˙Á‡ÌË Ò Ï‰ˈËÌÒÍÓ Ò˙ÒÚÓflÌË ËÎË Á‰‡‚̇ ËÌÚÂ‚Â̈Ëfl. (23). íÓ‚‡ ‚Íβ˜‚‡ ˆÂ̇ڇ ̇ ÔÓ‰ÛÍÚËÚÂ Ë ÛÒÎÛ„ËÚ ËÁÔÓÎÁ‚‡ÌË ‚ ÔÓˆÂÒ‡ ̇ „Ëʇ Á‡ Ô‡ˆËÂÌÚ‡ – ÓÒÌÓ‚ÌË Ô„ΉË, ÍÓÌÒÛÎÚ‡ÚË‚ÌË Ô„ΉË, ÒÔ¯ÌË Ì‡ÏÂÒË, ÎÂ͇ÒÚ‚‡, ωˈËÌÒÍÓ Ó·ÓÛ‰‚‡ÌÂ Ë ÍÓÌÒÛχÚË‚Ë. èÂÍËÚ ÌÂωˈËÌÒÍË ‡ÁıÓ‰Ë Ò‡ ÚÂÁË, ÍÓËÚÓ ÓÒË„Ûfl‚‡Ú ̇ Ô‡ˆËÂÌÚ‡ ‚Ò˘ÍË ÌÂÓ·ıÓ‰ËÏË ÌÂωˈËÌÒÍË ÔÓÚ·ÌÓÒÚË ●


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

– ı‡Ì‡, ̇ÒÚ‡Ìfl‚‡ÌÂ Ë Ú‡ÌÒÔÓÚ, ÌÂÓ·ıÓ‰ËÏË ÔÓ‡‰Ë ̇΢ÌÓÚÓ Á‡·ÓÎfl‚‡Ì ËÎË Ï‰ˈËÌÒ͇ χÌËÔÛ·ˆËfl. çÂÔÂÍËÚ ‡ÁıÓ‰Ë Ô‰ÒÚ‡‚Îfl‚‡Ú Á‡„Û·Ë ‚ ÔÓËÁ‚Ó‰ËÚÂÎÌÓÒÚÚ‡ ̇ Ë̉˂ˉ‡, ÔÓÓ‰ÂÌË ÓÚ ·ÓÎÂÒÚÚ‡ ËÎË ÔÂʉ‚ÂÏÂÌ̇ ÒÏ˙ÚÌÓÒÚ. í ‚Íβ˜‚‡Ú Ò˙˘Ó Ë Á‡„Û·ËÚ ÔÓÓ‰ÂÌË Ò‰ ÒÂÏÂÈÒÚ‚ÓÚÓ Ì‡ Ô‡ˆËÂÌÚ‡ ÔÓ ‚ÂÏ ̇ ÌÂÓ·ıÓ‰ËÏËÚ „ËÊË Á‡ Ì„Ó. ê‡ÁıÓ‰Ë ÔÓ‡‰Ë Á‡·Ó΂‡ÂÏÓÒÚ Ò ̇˜ÂÌË ÚÂÁË, ÍÓËÚÓ ÔÓËÁÚ˘‡Ú ÓÚ ÌÂÓÒ˙˘ÂÒÚ‚ÂÌËÚ ‰ÂÈÌÓÒÚË Ë ÎËÔÒ‡Ú‡ ̇ ÔÓ‰ÛÍÚË‚ÌÓÒÚ ÓÚ ·ÓÎÌËfl Ë̉˂ˉ. ê‡ÁıÓ‰Ë ÔÓ‡‰Ë ÒÏ˙ÚÌÓÒÚ Ò‡ ÓÌÂÁË ÔÓÔÛÒ̇ÚË ÔÓÎÁË, ÍÓËÚÓ Ë̉˂ˉ˙Ú Ì  ËχΠ‚˙ÁÏÓÊÌÓÒÚ ‰‡ Ô‰ÓÒÚ‡‚Ë ÔÓ‡‰Ë ÔÂʉ‚ÂÏÂÌ̇ڇ ÒË ÒÏ˙Ú. íÂÚË ‡ÒÔÂÍÚ Ì‡ ÌÂÔÂÍËÚ ‡ÁıÓ‰Ë Ô‰ÒÚ‡‚Îfl‚‡Ú Á‡„Û·ËÚ ̇ ÔÓËÁ‚Ó‰ËÚÂÎÌÓÒÚ ÓÚ ˜ÎÂÌ Ì‡ ÒÂÏÂÈÒÚ‚ÓÚÓ, ÍÓÈÚÓ Ì‡ÔÛÒ͇ ̇Ô˙ÎÌÓ ËÎË ˜‡ÒÚ˘ÌÓ ‡·ÓÚÌËÚ ÒË Á‡‰˙ÎÊÂÌËfl, Á‡ ‰‡ Ò „ËÊË Á‡ ·ÓÎÂÌ ·ÎËÁ˙Í. íÓÁË ÚËÔ Ë̉ËÂÍÚÌË ‡ÁıÓ‰Ë Ò ‰Ó·‡‚flÚ Í˙Ï ÓÒڇ̇ÎËÚÂ, Ô‰ËÁ‚Ë͇ÌË ÓÚ ·ÓÎÂÒÚÚ‡ ̇ Á‡·ÓÎÂÎËfl Ó‰ÌË̇. èËÏÂ Á‡ ˜ÂÒÚÓ Ò¢‡ÌË ÌÂÔÂÍË ‡ÁıÓ‰Ë Â Á‡„Û·‡Ú‡ ̇ ‚ÂÏ ÓÚ ÔË·„‡ÌÓ Î˜ÂÌË (‡Ï·Û·ÚÓÌÓ ËÎË ·ÓÎÌ˘ÌÓ), ÔÂÁ ÍÓÂÚÓ ·ÓÎÌËflÚ Â ÏÓ„˙Î ‰‡ ‡·ÓÚË Ë ‰‡ „ÂÌÂË‡ ÔËıÓ‰Ë. ä‡ÚÓ Ô‡‚ËÎÓ ÓÚ˜ËÚ‡ÌÂÚÓ ‚ ÏÓÌÂÚ‡ÌË Â‰ËÌËˆË Ì‡ ÚÓÁË ÚËÔ ‡ÁıÓ‰Ë ÒÚ‡‚‡ ËÁÍβ˜ËÚÂÎÌÓ ÚÛ‰ÌÓ (10). Intangible costs - ËÎË ÌÂËÁÏÂËÏËÚ ‡ÁıÓ‰Ë Ò‡ ÚÂÁË, ÍÓËÚÓ Ô‡ˆËÂÌÚ˙Ú ËÁÔËÚ‚‡ ÔÓ‡‰Ë ·ÓÎ͇ڇ Ë ÒÚ‡‰‡ÌËÂÚÓ, Ô˘ËÌÂÌË ÓÚ Á‡·ÓÎfl‚‡ÌÂÚÓ ËÎË ÌÂÊ·ÌËÚ ‡͈ËË ÓÚ ÔË·„‡ÌÓÚÓ Î˜ÂÌËÂ. Ç Ò‚ÂÚÓ‚ÂÌ Ï‡˘‡· Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËÚ ÔÓÛ˜‚‡ÌËfl ÔË ÂÔËÎÂÔÒËfl Ò‡ ‰Ó͇Á‡ÎË Ò‚ÓflÚ‡ Á̇˜ËÏÓÒÚ. ç‡È˜ÂÒÚÓ Ó·Ò˙ʉ‡ÌËflÚ ÔÓ·ÎÂÏ Â Ù‡χÍÓËÍÓÌÓÏ˘ÂÒ͇ڇ ˆÂÎÂÒ˙Ó·‡ÁÌÓÒÚ Ì‡ ÌÓ‚ÓÔ‰ÒÚ‡‚ÂÌËÚ ̇ Ô‡Á‡‡ ÚÂ‡Ô‚Ú˘ÌË ‡ÎÚÂ̇ÚË‚Ë Á‡ ΘÂÌË ̇ ÂÔËÎÂÒËfl (24). éÒ‚ÂÌ, ˜Â ÌÓÒflÚ ÔÓÚÂ̈ˇΠÁ‡ ÔÓ-‰Ó·‡ ÂÙÂÍÚË‚ÌÓÒÚ, ÌÓ‚ËÚ ‡ÌÚËÂÔËÎÂÔÚ˘ÌË Ï‰Ë͇ÏÂÌÚË, Ò‡ ‚ Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë Á̇˜ËÚÂÎÌÓ ÔÓ-ÒÍ˙ÔË Ë Ô‰·„‡Ú ÏÌÓ„Ó ÌÂËÁ‚ÂÒÚÌË ÔÓ ÓÚÌÓ¯ÂÌË ̇ ̇¯ËÚ Ә‡Í‚‡ÌËfl, Á‡Òfl„‡˘Ë ‡ÁıÓ‰ËÚ ҂Á‡ÌË Ò Úflı (6)? Persson PM /2003/ Ô‰ÒÚ‡‚fl ‰‡ÌÌË, ÒÔÓ‰ ÍÓËÚÓ Î˜ÂÌËÂÚÓ Ì‡ ÂÔËÎÂÔÒËfl Ò  ÓÒÍ˙ÔËÎÓ ÓÚ 1999 ‰Ó 2000 „. ¯ÂÒÚ Ô˙ÚË Ë ÚÓ Á‡ ÒÏÂÚ͇ ̇ ̇‡Ò̇ÎÓÚÓ Ô‰ÔËÒ‚‡ÌÂ Ë ÔÓ-‚ËÒÓÍËÚ ˆÂÌË Ì‡ ÌÓ‚ËÚ ‡ÌÚËÂÔËÎÂÔÚ˘ÌË Ï‰Ë͇ÏÂÌÚË (ÄÖå), ·ÂÁ ‰‡ Ëχ Ò˙˘ÂÒÚ‚Â̇ ÔÓÏfl̇ ‚ Ó·˘Ëfl ·ÓÈ Ì‡ Á‡·ÓÎÂÎËÚÂ. ç  Ôӂ‰ÂÌÓ Ó·‡˜Â ÔÓÛ˜‚‡ÌÂ, ÍÓÂÚÓ ‰‡ Á‡˘ËÚË Ú‡ÁË ÚẨÂ̈Ëfl ͇ÚÓ ÔÓ ËÁ„Ӊ̇ Ë Ó·ÛÒÎÓ‚Â̇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË . èÓ Ú‡ÁË Ô˘Ë̇ ‡‚ÚÓ˙Ú ËÁ‡Áfl‚‡ Ò˙ÏÌÂÌËfl Á‡ Ò˙ÓÚÌÓ¯ÂÌËÂÚÓ ˆÂ̇- ÂÙÂÍÚË‚ÌÓÒÚ Ì‡ ÌÓ‚ËڠωË͇ÏÂÌÚË Ë Ô‰·„‡ ‰‡ Ò Ôӂ‰ ̇ÒÓ˜ÂÌÓ ËÁÒΉ‚‡Ì ‚ Ú‡ÁË Ó·Î‡ÒÚ (25). ÑÛ„Ë ‡‚ÚÓË Ò˙˘Ó ÒÔÓ‰ÂÎflÚ ÚÓ‚‡ ‡Á·Ë‡Ì ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÔÓÒÚÓflÌÌÓ ‡ÒÚfl˘ËÚ ‡ÁıÓ‰Ë ‚ ӷ·ÒÚÚ‡ ̇ ÂÔËÎÂÔÒËflÚ‡. ä‡ÍÚÓ Á‡fl‚fl‚‡ Thomas SV. ‚ ‡·ÓÚ‡Ú‡ ÒË, ÔÓ-‚ËÒÓÍËÚ ˆÂÌË Ì‡ ÌÓ‚ËÚ ÄÖå, ˆÂ̇ڇ ̇ ÒÎÓÊÌË ÚÂ‡Ô‚Ú˘ÌË Ë ‰Ë‡„ÌÓÒÚ˘ÌË Ôӈ‰ÛË Ë ·ÓÎÌ˘ÌË ‡ÁıÓ‰Ë Ò‡ ÓÒÌÓ‚‡Ú‡ ̇ ÚÓÁË ÔÓ·ÎÂÏ. à̉ËÂÍÚÌËÚ ‡ÁıÓ‰Ë Ì‡ Ó·˘ÂÒÚ‚ÓÚÓ ÔÓ‡‰Ë Á‡„Û·‡ ̇ ÔÓËÁ‚Ó‰ËÚÂÎÌÓÒÚ ËÎË Ô‰‚‡ËÚÂÎ̇ ÒÏ˙Ú Ò‡ ÏÌÓ„ÓÍ‡ÚÌÓ ÔÓ-„ÓÎÂÏË ÓÚ ‰ËÂÍÚÌËÚÂ. ëÔÓ‰ ÚÓÁË ÍÓÎÂÍÚË‚ ÔÓ – ÌÓ‚ËڠωË͇ÏÂÌÚË ËÏ‡Ú Ô‰ËÏÒÚ‚Ó Ô‰ ÛÚ‚˙‰ÂÌËÚ ˘Ó Ò ÓÚ̇Òfl ‰Ó ÔÓÌÓÒËÏÓÒÚ, ·ÂÁÓÔ‡ÒÌÓÒÚ Ë ÎÂÒÌÓ ÔËÎÓÊÂÌËÂ. èÓÎÁËÚ ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÔÓ‰Ó·ÂÌ ÍÓÌÚÓΠ̇ ÔËÒÚ˙ÔËÚÂ Ë ÔÓ‰Ó·ÂÌÓ Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ, Ô‰·„‡ÌË ÓÚ ÚÂÁË ÌÓ‚Ë ÒÚ‡Ú„ËË Á‡ ΘÂÌË ̇ ÂÔËÎÂÔÒËfl Úfl·‚‡ ‰‡ Ò ӈÂÌfl‚‡Ú ‰ÌÓ‚ÂÏÂÌÌÓ Ò ÓˆÂÌ͇ڇ ̇ Ôӂ˯Â̇ڇ ˆÂ̇ ̇ ÔÂÔ‡‡ÚËÚÂ. èÓÌflÍÓ„‡ Ôӂ˯ÂÌËÚ ‡ÁıÓ‰Ë Á‡ ÔÓ-ÌÓ‚ËڠωË͇ÏÂÌÚË ÏÓÊ ‰‡ Ì ҇ ÓÔ‡‚‰‡ÌË Í‡ÚÓ ÂÙÂÍÚË‚ÌÓÒÚ Ì‡ ÔÂÔ‡‡Ú‡. Ç ‰Û„Ë ÒÎÛ˜‡Ë ÔÓÎÁ‡Ú‡ ÓÚ ÌÓ‚ËÚ ÔÂÔ‡‡ÚË Â ÌÂÒ˙ÏÌÂ̇, ÌÂÁ‡‚ËÒËÏÓ ÓÚ ˆÂ̇ڇ ËÏ (26).

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Ç ÔÓÛ˜‚‡Ì ̇ Arroyo S, Fossas P et al. 2000 „., Ôӂ‰ÂÌÓ Í‡ÚÓ cost-minimization study  ӘÂڇ̇ ÒËÚÛ‡ˆËflÚ‡ ‚ àÒÔ‡ÌËfl ÔË Ô‡ˆËÂÌÚË Ì‡ ÏÓÌÓÚÂ‡ÔËfl. Ç ÔÓÛ˜‚‡ÌÂÚÓ Ò‡ ‚Íβ˜ÂÌË Ô‡ˆËÂÌÚË Ì‡ ÏÓÌÓÚÂ‡ÔËfl Ò lamotrigine (LTG), carbamazepine (CBZ), phenytoin (PHT) and valproic acid (VPA) ͇ÚÓ Ò‡ Ò‡‚ÌÂÌË ‡ÁıÓ‰ËÚÂ(Ò‡ÏÓ ÔÂÍË ‡ÁıÓ‰Ë) ÔÓÓ‰ÂÌË ÓÚ Î˜ÂÌËÂÚÓ. àÁ·Ó˙Ú Ì‡ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËflÚ ‡Ì‡ÎËÁ ÚËÔ cost-minimization  ӷÓÒÌÓ‚‡Ì ÓÚ ‰‡ÌÌË ÓÚ ‡Ì‰ÓÏËÁË‡ÌË ÔÓÛ˜‚‡ÌËfl Á‡Íβ˜‡‚‡˘Ë, ˜Â Ìflχ Á̇˜Ëχ ‡ÁÎË͇ ‚ ÂÙÂÍÚË‚ÌÓÒÚÚ‡ ̇ Ô‰ÎÓÊÂÌËڠωË͇ÏÂÌÚË. êÂÁÛÎÚ‡ÚËÚ ÔÓ͇Á‚‡Ú ˜Â ‚ àÒÔ‡ÌËfl ΘÂÌËÂÚÓ Ò LTG  ‰‚‡ ‰Ó ÚË Ô˙ÚË ÔÓ –ÒÍ˙ÔÓ ÓÚ ÓÒڇ̇ÎËڠωË͇ÏÂÌÚË. èË ‰Ó͇Á‡Ì‡Ú‡ ÎËÔÒ‡ ̇ ‡ÁÎË͇ ÂÙÂÍÚË‚ÌÓÒÚÚ‡, ÚÂÁË ‰‡ÌÌË Ó˜ÂÚ‡‚‡Ú ÚÓÁË ÔÂÔ‡‡Ú, ͇ÚÓ ÔÓ-ÌÂËÁ„Ó‰ÂÌ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË Á‡ ÔÂÔ‡‡Ú ̇ Ô˙‚Ë ËÁ·Ó (27). èË ‡Á„ÎÂʉ‡Ì ̇ ÔÓ·ÎÂχ ‚ ÔÓ-¯ËÓÍ ‡ÒÔÂÍÚ Ë ‡Ì‡ÎËÁË‡Ì ̇ ÒËÚÛ‡ˆËflÚ‡ ‚ Ö‚ÓÔ‡, Heaney DC, Shorvon SD, Sander JW et. al Ò‡‚Ìfl‚‡ÈÍË ÏÓÌÓÚÂ‡ÔËflÚ‡ Ò ÚÂÁË ˜ÂÚËË Ï‰Ë͇ÏÂÌÚ‡ Ò˙˘Ó ÛÒÚ‡ÌÓ‚fl‚‡Ú ‰‚‡ ‰Ó ÚË Ô˙ÚË ÔÓ-„ÓÎÂÏË ‡ÁıÓ‰Ë Ì‡ LTG ‚ Ò‡‚ÌÂÌËÂ Ò ÓÒڇ̇ÎËÚ (28). èÓ‰Ó·ÌË ÂÁÛÎÚ‡ÚË Ò‡ ÔÓÎÛ˜ÂÌË Ë ÓÚ van Hout ÔÂÁ 2003 „., ÍÓ„‡ÚÓ Ò‡‚Ìfl‚‡ ‰‚‡ ÔÂÔ‡‡Ú‡ ËÁÔÓÎÁ‚‡ÌË Í‡ÚÓ ÏÓÌÓÚÂ‡ÔËfl lamotrigine Ë topiramate ÔË ÎËÔÒ‡Ú‡ ̇ ‰ËÂÍÚÌË Ò‡‚ÌËÚÂÎÌË ‰‡ÌÌË (6). ä‡ÍÚÓ ·Â ÒÔÓÏÂ̇ÚÓ ÔÓ-„Ó هχÍÓËÍÓÌÓÏ˘ÂÒÍËÚ ‰‡ÌÌË Ì ·Ë‚‡ ‰‡ ·˙‰‡Ú ÓÔ‰ÂÎfl˘Ë ‚ ËÁ·Ó˙Ú Ì‡ ÚÂ‡Ô‚Ú˘ÌÓ Ôӂ‰ÂÌË ÓÚ ÓÚ‰ÂÎÌËfl ÎÂ͇ ÒÔflÏÓ ÍÓÌÍÂÚÌËfl Ô‡ˆËÂÌÚ. í ӷ‡˜Â Ò‡ ‚Ó‰Â˘Ë ÔË ÓÔ‰ÂÎflÌ ̇ ÎÂ͇ÒÚ‚Â̇ڇ ÔÓÎËÚË͇. íÓ‚‡  ÓÒÓ·ÂÌÓ ‚flÌÓ Á‡ ÚÂÁË ‰˙ʇ‚Ë, ˜ËËÚÓ ÂÒÛÒË ‚ Á‰‡‚ÂÓÔ‡Á‚‡ÌÂÚÓ Ò‡ ÒËÎÌÓ Ó„‡Ì˘ÂÌË. Ç Ò‚Ó ÔÓÛ˜‚‡Ì ÓÚ 1999 „. Á‡ ËÁÔÓÎÁ‚‡ÌÂÚÓ, Ô‰ÔËÒ‚‡ÌÂÚÓ Ë Ù‡χÍÓËÍÓÌÓÏË͇ڇ ̇ ÄÖå ‚ à̉Ëfl Radhakrishnan K, Nayak SD et al. ÔÓ͇Á‚‡Ú, ˜Â Ì‡È ˜ÂÒÚÓ ËÁÔÓÎÁ‚‡ÌËڠωË͇ÏÂÌÚË Ò‡ Carbamazepine Ë diphenylhydantoin (DPH), ÔÓÒΉ‚‡ÌË ÓÚ valproate Ë phenobarbitone. è‰ÔÓ˜ËÚ‡ÌËflÚ‡ Í˙Ï ÚÂÁË Ï‰Ë͇ÏÂÌÚË Ò‡ ͇ÍÚÓ ÔÓ‡‰Ë Úflı̇ڇ ‰Ó͇Á‡Ì‡ ÂÙÂÍÚË‚ÌÓÒÚ Ë ÌËÒ͇ ˆÂ̇, ڇ͇ ÔÓ‡‰Ë ÎËÔÒ‡Ú‡ ̇ ‰ÓÒÚ‡Ú˙˜Ì‡ ËÌÙÓÏË‡ÌÓÒÚ Ì‡ ÎÂÍÛ‚‡˘ËÚ ÎÂ͇Ë Á‡ ̇΢ÌËÚ ÌÓ‚Ë ÏÂÚÓ‰Ë Á‡ Ù‡χÍÓÚÂ‡ÔËfl (29). Ç ÔÓ‰Ó·ÌÓ ÔÓÛ˜‚‡Ì ̇ Krishnan et al. ÓÚ 2004 „Ó‰Ë̇ ‰Ó͇Á‚‡, ˜Â Ô‡‚ËÎÌÓÚÓ Î˜ÂÌË ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ, ‰ÓË Ë Ò Ì‡È-‚ÚËÌËÚ ̇΢ÌË Ï‰Ë͇ÏÂÌÚË ÓÒË„Ûfl‚‡ Á̇˜ËÚÂÎÌË ÔÓÎÁË Á‡ Ó·˘ÂÒÚ‚ÓÚÓ ÔÓ‰ ÙÓχڇ ̇ ÂÎËÏËÌË‡Ì ̇ Á‡„Û·Ë Ì‡ ÔÓËÁ‚Ó‰ËÚÂÎÌÓÒÚÚ‡ Ë Û‚Â΢‡‚‡Ì ̇ ·ÛÚÌËfl ‚˙Ú¯ÂÌ ÔÓ‰ÛÍÚ. íÂÁË ÔÓÎÁË Ì‡Ï‡Îfl‚‡Ú ÔË ËÁÔÓÎÁ‚‡Ì ̇ ÒÍ˙ÔÓÒÚÛ‚‡˘Ë ωË͇ÏÂÌÚË, ÌÓ ‚˙ÔÂÍË ÚÓ‚‡ ÚÂÊÂÒÚÚ‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ ‚˙ıÛ Ó·˘ÂÒÚ‚ÓÚÓ Â ÚÓÎÍÓ‚‡ Á̇˜Ëχ, ˜Â ‚ÒÂÍË ÎÂÍÛ‚‡Ì Ô‡ˆËÂÌÚ ÒÚÛ‚‡ ÔÓ-χÎÍÓ ÓÚÍÓÎÍÓÚÓ ‚ÂÓflÚÌËÚ Á‡„Û·Ë (30). Ç Ò‚ÓflÚ‡ ‡·ÓÚ‡ ÓÚ 2005 „Ó‰Ë̇ Neil Hawkins, Epstein D, Drummond M, Wilby J, ÔÓÛ˜‚‡Ú ÛÚÓ˜ÌÂÌËÚ ÚÂ‡Ô‚Ú˘ÌË ÒıÂÏË Á‡ ΘÂÌË ̇ ÂÔËÎÂÔÒËfl ‚ é·Â‰ËÌÂÌÓÚÓ Í‡ÎÒÚ‚Ó, ÔÓ ÓÚÌÓ¯ÂÌË ̇ Úflı̇ڇ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒ͇ ÒÚÓÈÌÓÒÚ. íÂıÌËÚ ÂÁÛÎÚ‡ÚË ÔÓ͇Á‚‡Ú, ˜Â Á‡ ÌÓ‚Ó ‰Ë‡„ÌÓÒÚˈË‡ÌË Ô‡ˆËÂÌÚË Ò Ô‡ˆË‡ÎÌË ÔËÒÚ˙ÔË, ͇·‡Ï‡ÁÂÔËÌ Ë ‚‡ÎÔÓ‡Ú Ò‡ ̇È-ËÁ„Ó‰ÌËÚ ͇ÚÓ ˆÂ̇/ÂÙÂÍÚË‚ÌÓÒÚ ÔË·„‡ÌË Í‡ÚÓ ÏÓÌÓÚÂ‡ÔËfl. ä‡·‡Ï‡ÁÂÔËÌ˙Ú Â Ò Ì‡È-‰Ó·˙ ÔÓÙËΠ̇ ˆÂ̇/ÂÙÂÍÚË‚ÌÓÒÚ Í‡ÚÓ ‚ÚÓË ‰ ÚÂ‡Ô‚Ú˘ÌÓ Ò‰ÒÚ‚Ó Á‡ ÂÙ‡ÍÚÂÌË Ô‡ˆËÂÌÚË, ‡ ÓÍÒ͇·‡ÁÂÔËÌ˙Ú – ͇ÚÓ ‰Ó·‡‚˙˜Ì‡ ÚÂ‡ÔËfl Á‡ ÔÓ‰Ó·ÌË Ô‡ˆËÂÌÚË, ‡ÍÓ “„ÓÚÓ‚ÌÓÒÚÚ‡ Á‡ Ô·˘‡Ì” Á‡ ‰ÓÔ˙ÎÌËÚÂÎÌË Á‰‡‚ÌË ÔÓÎÁË Â ÔÓ-„ÓÎflχ ÓÚ 18,000 Á‡ QALY/quality-adjusted life year/. ᇠԇˆËÂÌÚË Ò ÌÓ‚ÓÓÚÍËÚË „ÂÌÂ‡ÎËÁË‡ÌË ÔËÒÚ˙ÔË, ‚‡ÎÔÓ‡Ú Ò Ó͇Á‚‡ ̇ÈÔÓ‰ıÓ‰fl˘ ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÔÓÙË· ÒË ˆÂ̇/ÂÙÂÍÚË‚ÌÓÒÚ, ‡ Á‡ Ú‡ÍË‚‡ Ò „ÂÌÂ‡ÎËÁË‡ÌË, ÂÙ‡ÍÚÂÌË Ì‡ ΘÂÌË ÔËÒÚ˙ÔË – ̇È-ËÁ„Ó‰ÂÌ Â ÚÓÔË‡Ï‡Ú (31). êÂÁÛÎ-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

Ú‡ÚËÚ ÓÚ ÚÓ‚‡ ÔÓÛ˜‚‡Ì ӘÂÚ‡‚‡Ú ÒÚÛÍÚÛ‡Ú‡ ̇ ÚÂ‡Ô‚Ú˘ÌÓÚÓ Ôӂ‰ÂÌË ‚ ‰̇ ‚ÓÔÂÈÒ͇ ÒÚ‡Ì‡, ˘Ó Ò ÓÚ̇Òfl ‰Ó ÓÔÚËχÎÌÓÚÓ ‡ÁÔ‰ÂÎÂÌË ̇ ÂÒÛÒËÚ Á‡ ΘÂÌË ̇ Ô‡ˆËÂÌÚËÚÂ Ò ÂÔËÎÂÔÒËfl. ᇉ˙ηӘÂÌËflÚ ‡Ì‡ÎËÁ ̇ ‡‚ÚÓËÚ ÔÓ͇Á‚‡, ˜Â ÌÓ‚ËڠωË͇ÏÂÌÚË, ËÁÔÓÎÁ‚‡ÌË Á‡ ΘÂÌË ̇ ÌÓ‚ÓÓÚÍËÚ‡ ÂÔËÎÂÔÒËfl, Ô‰ËÁ‚ËÍ‚‡Ú ÔÓ-„ÓÎÂÏË ‡ÁıÓ‰Ë ÓÚ ÛÚ‚˙‰ÂÌËÚ ÄÖå, ‡ ÓÒË„Ûfl‚‡Ú ͇ÚÓ ÂÁÛÎÚ‡Ú ÔÓ‰Ó·ÌË Á‰‡‚ÌË ÔÓÎÁË. ëËÚÛ‡ˆËflÚ‡ ‚ ÒÚ‡ÌËÚ ÓÚ íÂÚËfl Ò‚flÚ ËÁÒΉ‚‡ ‚ ÔÓÛ˜‚‡Ì ÓÚ 2005 Dan Chisholm (32). ëÔÓ‰ Ô‰ÒÚ‡‚ÂÌËÚ ÓÚ ÌÂ„Ó ‰‡ÌÌË, ‚ ÌflÍÓË „ËÓÌË ÓÚ Ò‚ÂÚ‡ (ÓÒÚ‡‚‡ ‰‡ Ò Á‡ÔËڇϠ–ä˙‰Â Ò ̇ÏË‡Ï ÌËÂ?), ‚Ò Ӣ Ò˙˘ÂÒÚ‚Û‚‡ Á̇˜ËÚÂÎÂÌ Ì‰ÓÒÚË„ ‚ ‡ÁÔ‰ÂÎÂÌËÂÚÓ Ì‡ ÂÒÛÒËÚ Á‡ ΘÂÌË ̇ ÂÔËÎÂÔÒËfl, ‚˙ÔÂÍË ÛÒÚ‡ÌÓ‚ÂÌÓÚÓ Í‡Ú„Ó˘ÌÓ ‚ÎËflÌË ̇ ÚÓ‚‡ Á‡·ÓÎfl‚‡ÌÂ, ‚˙ıÛ Ó·˘ÂÒÚ‚ÂÌÓÚÓ Á‰‡‚Â. Ä‚ÚÓËÚ ҇ ÒË ÔÓÒÚ‡‚ËÎË Á‡‰‡˜‡Ú‡ ‰‡ ‰Ó͇ʇÚ, ˜Â Ô‡‚ËÎÌÓÚÓ Î˜ÂÌË  Ì ҇ÏÓ ËÁ„Ó‰ÌÓ ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÒÔÂÒÚfl‚‡Ì ̇ Ó·˘ÂÒÚ‚ÂÌË ÂÒÛÒË, ÌÓ Ë ˜Â Ì  ÌÂÔÂÏÂÌÌÓ ÒÍ˙ÔÓ. ÖÙÂÍÚË‚ÌÓÒÚÚ‡  ËÁ‡ÁÂ̇ ˜ÂÁ DALY (disability-adjusted life years – „Ó‰ËÌË Ì‡ ÊË‚ÓÚ ‚ Û‚‰ÂÌÓ Ò˙ÒÚÓflÌËÂ), ÍÓËÚÓ ÏÓ„‡Ú ‰‡ Ò ËÁ·Â„̇Ú, ˜ÂÁ ÔËÎÓÊÂÌË ̇ ‡‰ÂÍ‚‡ÚÌÓ Î˜ÂÌËÂ, ‡ ‡ÁıÓ‰ËÚ – ˜ÂÁ ËÌÚÂ̇ˆËÓ̇ÎÌË ‰Ó·Ë /I$/. Ä‚ÚÓ˙Ú ÛÒÚ‡ÌÓ‚fl‚‡, ˜Â ‡Á¯Ëfl‚‡ÌÂÚÓ Ì‡ Ô‡‚ËÎÌÓÚÓ ËÁÔÓÎÁ‚‡Ì ̇ ÄÖå Ò 50% ‚ ‰Â‚ÂÚ ‰˙ʇ‚Ë, ·Ë ÒÔÂÒÚËÎÓ ÏÂÊ‰Û 150-650 DALYs ̇ ‰ËÌ ÏËÎËÓÌ Ì‡ÒÂÎÂÌËÂ, ‡‚Ìfl‚‡˘Ë Ò ̇ ÓÚ 13 ‰Ó 40 % ÓÚ Ó·˘ÂÒÚ‚Â̇ڇ ÚÂÊÂÒÚ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ. íÓ‚‡ Ôӂ‰ÂÌË ‰‡‚‡ ÓÔËÒ‡ÌËÚ ‰Ó·Ë ÂÁÛÎÚ‡ÚË, ÔË „Ӊ˯ÂÌ ‡ÁıÓ‰ per capita ÓÚ I$ 0.20-1.33, ͇ÚÓ ÛÚ‚˙‰ÂÌËÚ “ÒÚ‡Ë” ‡ÌÚËÂÔËÎÂÔÚ˘ÌË Ï‰Ë͇ÏÂÌÚË Ò‡ ÓÚÌÓ‚Ó Ì‡È-ËÁ„Ó‰ÌË ÔÓ‡‰Ë Úflı̇ڇ ‰Ó·‡ ÂÙÂÍÚË‚ÌÓÒÚ Ë ÌËÒ͇ ˆÂ̇ Á‡ ÒÔÂÒÚfl‚‡Ì ̇ DALY / I$ 800-2,000 Á‡ ‚Òfl͇ ËÁ·Â„̇ڇ DALY/. éÒÌÓ‚ÌËÚ Á‡Íβ˜ÂÌËfl, ÍÓËÚÓ Ô‡‚Ë ‡‚ÚÓ˙Ú Ò‡, ˜Â Á̇˜ËÚÂÎ̇ ˜‡ÒÚ ÓÚ Ì‡ÒÚÓfl˘‡Ú‡ ÚÂÊÂÒÚ Ì‡ ÂÔËÎÂÔÒËflÚ‡ ‚˙ıÛ Ó·˘ÂÒÚ‚ÓÚÓ, ‚ ‡Á‚Ë‚‡˘ËÚ Ò ÒÚ‡ÌË, ÏÓÊ ‰‡ ·˙‰Â ÒÔÂÒÚÂ̇, ˜ÂÁ ÔÓ‰Ó·fl‚‡Ì ̇ ËÁÔÓÎÁ‚‡ÌÂÚÓ Ì‡ ÄÖå Ò ÌËÒ͇ ˆÂ̇ Ë ‰Ó·‡ ÂÙÂÍÚË‚ÌÓÒÚ, Á‡Ô‡Á‚‡ÈÍË ÌÓ‚ËÚ – ÔÓ-ÒÍ˙ÔË Ï‰Ë͇ÏÂÌÚË Á‡ ÒËÚÛ‡ˆËËÚÂ, ‚ ÍÓËÚÓ Ìflχ ‰Û„ ÚÂ‡Ô‚Ú˘ÂÌ ËÁıÓ‰. éÔËÒ‡ÌËÚ ÂÁÛÎÚ‡ÚË ÔÓ͇Á‚‡Ú „Ή̇ڇ ÚӘ͇ ̇ Ô·ڈËÚÂ Ë Ó·˘ÂÒÚ‚ÓÚÓ ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÒӈˇÎÌËfl ÂÙÂÍÚ Ì‡ ÂÔËÎÂÔÒËflÚ‡. Ç˙ÔÂÍË, ˜Â ̇¯ËÚ ‡Á·Ë‡ÌËfl Á‡ ωˈËÌÒÍËÚ ‡ÒÔÂÍÚË Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ ‰‡ Ò‡ ̇‡Ò̇ÎË Á̇˜ËÚÂÎÌÓ, ‚Ò Ӣ ÌÂωˈËÌÒÍËÚ ‚˙ÔÓÒË ˜ÂÒÚÓ Ò ÔÂÌ·„‚‡Ú, Ì Ò ‰Ë‡„ÌÓÒÚˈË‡Ú Ë fl‰ÍÓ Ò ÎÂÍÛ‚‡Ú (33). åÌÓÊÂÒÚ‚Ó ÓÚ ÔÛ·ÎË͇ˆËË ÔÓ͇Á‚‡Ú, ˜Â ÔËÒÚ˙Ô̇ڇ ˜ÂÒÚÓÚ‡ Ë ÚÂÊÂÒÚ Ò‡ ÓÒÌÓ‚ÌË Ù‡ÍÚÓË Á‡ ‚ÎÓ¯‡‚‡ÌÂÚÓ Ì‡ ÔÒËıÓÎӄ˘ÂÒÍÓÚÓ Ò˙ÒÚÓflÌË ̇ Ô‡ˆËÂÌÚ‡ Ë Í‡˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ (34, 35, 36, 37, 38). 臈ËÂÌÚËÚÂ Ò ÔÓ-˜ÂÒÚË ÔËÒÚ˙ÔË Ì ҇ÏÓ ËÏ‡Ú ÔÓ –ÎÓ¯Ó Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ, ÌÓ Ë ‡ÁıÓ‰ËÚ ÔÓ ÚflıÌÓÚÓ Î˜ÂÌË ҇ ‰Ó ÔÂÚ Ô˙ÚË ÔÓ-„ÓÎÂÏË (39). á‰‡‚ÌËÚ ÒÔˆˇÎËÒÚË Ë ‰ÓË Ò‡ÏËÚ ԇˆËÂÌÚË, ‚ Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë ÔÂÌ·„‚‡Ú ‚ÎËflÌËÂÚÓ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ ‚˙ıÛ Âʉ̂ÌËfl ÊË‚ÓÚ. íÓ‚‡ Ò ÓÚ̇Òfl Ì ҇ÏÓ Á‡ Ô‡ˆËÂÌÚËÚÂ, ÔË ÍÓËÚÓ Ì  ÔÓÒÚË„Ì‡Ú ‰Ó·˙ ÍÓÌÚÓΠ̇ ÔËÒÚ˙ÔËÚÂ, ÌÓ Ë Á‡ ÚÂÁË ÔË ÍÓËÚÓ Ì‡ Ô˙‚ ÔӄΉ Á‡·ÓÎfl‚‡ÌÂÚÓ Â ‰Ó· ÍÓÌÚÓÎË‡ÌÓ Ë Ì ·Ë Úfl·‚‡ÎÓ ‰‡ ‚ÎËfl ‚˙ıÛ Í‡˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ. Ç Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë Ô‡ˆËÂÌÚËÚ Ò˙Ó·˘‡‚‡Ú Á‡ ÌÂÊ·ÌË ‡͈ËË ÓÚ ÔË·„‡Ì‡Ú‡ ÚÂ‡ÔËfl, ͇ÚÓ ÓÒÓ·ÂÌÓ ˜ÂÒÚË Ò‡ ÍÓ„ÌËÚË‚ÌËÚ ÂÙÂÍÚË. ëÚ‡ı˙Ú, Ó„‡Ì˘ÂÌËflÚ‡ ‚ ÒÚË· ̇ ÊË‚ÓÚ Ë Ò˙Á‰‡‰Â̇ڇ ÓÚ Á‡·ÓÎfl‚‡ÌÂÚÓ ÒÚ˄χ, Ò ӈÂÌfl‚‡Ú ÓÚ Ô‡ˆËÂÌÚËÚ ͇ÚÓ Ì‡È-ÎÓ¯Ëڠ̢‡ ÓÚ ÚÓ‚‡ ‰‡ ÒË ·ÓÎÂÌ ÓÚ ÂÔËÎÂÔÒËfl (40). èÒËıÓÎӄ˘ÂÒÍËÚ ÔÓ·ÎÂÏË ÏÓ„‡Ú ‰‡ Ò‡ ÂÁÛÎÚ‡Ú Í‡ÍÚÓ ÔflÍÓ ÓÚ Á‡·ÓÎfl‚‡ÌÂÚÓ Ë Î˜ÂÌËÂÚÓ ÏÛ, ڇ͇ Ë ÌÂÔflÍÓ ÓÚ ÔÓÒΉˈËÚ ÓÚ Ù‡ÍÚ‡, ˜Â Ô‡ˆËÂÌÚ˙Ú ÊË‚ÂÂ Ò ÌÂÔ‰‚Ë-

68

‰ËÏÓ, ıÓÌ˘ÌÓ Á‡·ÓÎfl‚‡ÌÂ. éˆÂÌ͇ڇ Ë ÓÚÍË‚‡ÌÂÚÓ Ì‡ Ú‡ÍË‚‡ ÔÒËıÓÎӄ˘ÂÒÍË ÔÓ·ÎÂÏË ·Ëı‡ ÏÓ„ÎË ‰‡ ·˙‰‡Ú Ô‡‚ÂÌË ÓÚ ÎÂÍÛ‚‡˘Ëfl ωˈËÌÒÍË ÔÂÒÓ̇Î, ‚ Ôӂ˜ÂÚÓ ÒÎÛ˜‡Ë ·ÂÁ ̇ÏÂÒ‡ ̇ ÒÔˆˇÎËÒÚË-ÔÒËıÓÎÓÁË. ᇠ‰‡ Ò ̇Ô‡‚Ë Ô˙‚‡Ú‡ ÒÚ˙Ô͇ ‚ ÚÓÁË ÔÓˆÂÒ Â ÌÂÓ·ıÓ‰ËÏÓ ‰‡ Ò ÔËÎÓÊË ÛÒÚ‡ÌÓ‚ÂÌ, ÒÚ‡·ËÎÂÌ Ë Ó·ÂÍÚË‚ÂÌ ÏÂÚÓ‰ Á‡ ÓˆÂÌ͇ ̇ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ, ÍÓÈÚÓ ‰‡ ÏÓÊ ‰‡ ·˙‰Â ÔË·„‡Ì ‚ ÍÎËÌ˘ÌË ÛÒÎÓ‚Ëfl. éˆÂÌ͇ڇ Úfl·‚‡ ‰‡ Ó·ı‚‡˘‡ ‚ χÍÒËχÎ̇ ÒÚÂÔÂÌ ‰ÂÒÂÚÚ ÓÒÌÓ‚ÌË ÙÛÌ͈ËÓ̇ÎÌË Í‡Ú„ÓËË, Á‡Ò„̇ÚË Ì‡È-˜ÂÒÚÓ ÓÚ Á‡·ÓÎfl‚‡ÌÂÚÓ. í ӷı‚‡˘‡Ú: ÒËÏÔÚÓχÚË͇, ÙÛÌ͈ËÓ̇ÎÂÌ ÒÚ‡ÚÛÒ, ÒӈˇÎÌÓ ÙÛÌ͈ËÓÌË‡ÌÂ, Ò˙Ì Ë ÔӘ˂͇, ÂÌÂ„˘ÌÓÒÚ, ‚˙ÁÔËflÚË ̇ Á‰‡‚ÂÚÓ, Ó·˘‡ Û‰Ó‚ÎÂÚ‚ÓÂÌÓÒÚ ÓÚ ÊË‚ÓÚ‡, ÓÎÂ‚Ë ‰ÂÈÌÓÒÚË, ÂÏÓˆËÓ̇ÎÂÌ ÒÚ‡ÚÛÒ Ë ÍÓ„ÌˈËfl (5). ë˙Á‰‡‰ÂÌË Ò‡ ÏÌÓ„Ó ‡Á΢ÌË ‚˙ÔÓÒÌˈË- Washington Psychosocial Seizure Inventory (WPSI), Social Effects Scale, Epilepsy Surgery Inventory (ESI-55), Quality of life in Epilepsy- QOLIE. ÇÒ˘ÍË Ú ҇ ‰Ó͇Á‡ÎË Ò‚ÓflÚ‡ ÂÙÂÍÚË‚ÌÓÒÚ, ÛÒÚÓȘ˂ÓÒÚ ÔË ÔÓ‚Â͇ Ë ÔÓ‚ÚÓflÂÏÓÒÚ Ì‡ ÚÂÒÚÓ‚ÂÚÂ Ë Ò‡ ÔÓ‰‡ÚÎË‚ÓÒÚ Ì‡ ÔÓÏfl̇ ÔË ÌÂÓ·ıÓ‰ËÏÓÒÚ, ÔÓ‡‰Ë ÍÛÎÚÛÌË, ÒӈˇÎÌË ËÎË ÂÎË„ËÓÁÌË Ô˘ËÌË. àÁ·Ó˙Ú Ì‡ ÏÂÚÓ‰ ÓÒÚ‡‚‡ ‚ ˙ˆÂÚ ̇ ÍÎËÌˈËÒÚ‡ ËÎË ËÁÒΉӂ‡ÚÂÎfl, ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ ËÁÒΉ‚‡ÌËfl ÍÓÌÚËÌ„ÂÌÚ Ë ÔÓÒÚ‡‚flÌËÚ ˆÂÎË. àÁÒΉ‚‡ÌËfl ÔÓ͇Á‚‡Ú, ˜Â ÍÎËÌ˘ÌÓ Á̇˜Ëχ ÔÓÏfl̇ ‚ ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ ÏÓÊ ‰‡ ·˙‰Â ÛÒÚ‡ÌÓ‚Â̇ Ò ÎÂÒÌËfl Á‡ ÔËÎÓÊÂÌË ‚˙ÔÓÒÌËÍ QOLIE –31, ÍÓÂÚÓ „Ó Ô‡‚Ë Ô‰ÔÓ˜ËÚ‡Ì ÔË ÏÌÓ„Ó ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl (41). è‰ÒÚ‡‚ÂÌËÚ ‚ÓÔÂÈÒÍË Ë Ò‚ÂÚÓ‚ÌË ‰‡ÌÌË, ͇ÍÚÓ Ë Ì‡‡ÒÚ̇ÎËflÚ ·ÓÈ Ì‡ Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍËÚ ÔÓÛ˜‚‡ÌËfl ‚ Ò‚ÂÚÓ‚ÂÌ Ï‡˘‡· Ò‡ ‰Ó͇Á‡ÚÂÎÒÚ‚Ó, ˜Â Ú ÓÒË„Ûfl‚‡Ú ‰̇ ÌÂÓ·ıÓ‰Ëχ „Ή̇ ÚӘ͇, ·ÂÁ ÍÓflÚÓ Â ÌÂÏËÒÎËÏÓ ‚ ̇¯Ë ‰ÌË ‰‡ ·˙‰Â Òڇ̉‡ÚËÁË‡ÌÓ ‰Ë‡„ÌÓÒÚ˘ÌÓ Ë ÚÂ‡Ô‚Ú˘ÌÓ Ôӂ‰ÂÌË ÔÓ ‚ÒÂÍË Â‰ËÌ Ï‰ˈËÌÒÍË ÔÓ·ÎÂÏ (42, 43). ᇠËÁ„‡Ê‰‡ÌÂÚÓ Ì‡ ˆÂÎÂÒ˙Ó·‡ÁÌÓ ÚÂ‡Ô‚Ú˘ÌÓ Ôӂ‰ÂÌË ‚ ӷ·ÒÚÚ‡ ̇ ÂÔËÎÂÔÒËflÚ‡ ‚ ̇¯‡Ú‡ ÒÚ‡Ì‡ ·Ë Úfl·‚‡ÎÓ ‰‡ ·˙‰‡Ú Ôӂ‰ÂÌË ÍÓÎÍÓÚÓ ÏÓÊ Ôӂ˜ ӷÂÍÚË‚ÌË Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁË. чÌÌËÚÂ,ÔÓÎÛ˜ÂÌË ÓÚ ÚÂÁË ÔÓÛ˜‚‡ÌËfl ÏÓ„‡Ú ‰‡ ÔÓÒÎÛÊ‡Ú Í‡ÚÓ ÓËÂÌÚË Á‡ ÓÒË„Ûfl‚‡Ì ̇ ÔÓ-ˆÂÎÂÒ˙Ó·‡ÁÌÓ, ÓËÂÌÚË‡ÌÓ Í˙Ï Ô‡ˆËÂÌÚ‡ Ë Ì„ӂËÚ ÌÛÊ‰Ë Î˜ÂÌËÂ Ò ‚ËÒÓ͇ ÂÙÂÍÚË‚ÌÓÒÚ, ÓÒË„Ûfl‚‡˘Ó χÚÂˇÎÌË Ë ÌÂχÚÂˇÎÌË ÔÓÎÁË Ë ÔÓ‰Ó·fl‚‡˘Ó ͇˜ÂÒÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ. ãàíÖêÄíìêÄ 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

á‡ı‡Ë‚ á, ï‡ÌÓ‚ ã, ÖÔËÎÂÔÒËfl, ëÓÙËfl 1999 „. åËı‡ÈÎÓ‚‡ å, éÒÌÓ‚ÌË ÔË̈ËÔË Ì‡ Á‰‡‚̇ڇ ËÍÓÌÓÏË͇, á‰‡‚̇ àÍÓÌÓÏË͇, ëÓÙËfl, 2001, ëÚÓ‚Ë –ãÂÒË˜Â‚Ó ç¯‚ É, Ç·ıÓ‚ Ç. Ë ÍÓÎÂÍÚË‚, î‡χÍÓËÍÓÌÓÏË͇, ÉÓÂÍÒèÂÒ, ëÓÙËfl 1999 „. Fleurence R. An introduction to health economics. The pharmaceutical journal, Nov 2003, Vol.271, p. 680-1. Baker G, Assessment of quality of life in people with epilepsy. Some practical implications. Epilepsia 2001 July 42 (s3): 66-69 van Hout BA, Gagnon DD, McNulty P, O'Hagan A. The cost effectiveness of two new antiepileptic therapies in the absence of direct comparative data: a first approximation. Pharmacoeconomics. 2003;21(5):315-26 Folland S, Goodman AC, Stano M: The Economics of Health and Health Care, ed 2. 1997 Upper Saddle River, N.J., Prentice-Hall,. Arrow KJ: Uncertainty and the welfare economics of medical care. American Economics Reviews 1963; 53:941-973 McGhan W. Rowland C, Bootman J: Cost benefit and cost-effectiveness: Methodologies for evaluating innovative pharmaceutical services. Am J Hosp Pharm 1978;35:133-140 Wilson Ä.De-Mystifying Pharmacoeconomics Drug Benefit Trends 1999 Cliggott Publishing; 11(5):56-67. Langfitt J, Wiebe S. Cost-effectiveness of epilepsy therapy: how should treatment effects be measured? Epilepsia. 2002;43 (4):17-24. Andrews FM & Withey SB. Social indicators of well being: Americans' perceptions o life quality. New York: Plenum Press, 1976 Calman KC. Quality of life in cancer patients: a hypothesis. J Med Ethics 1984;10:124-7. Hunt SM, McKenna SP, McEwan J, et al. A quantitative approach to perceived health status: a validation study. J Epidemiol Community Health 1980;34:281-96. Schipper H, Clinch J, Powell V. Definitions and conceptual issues. In: Spilker B, ed. Quality of life assessment in clinical trials. New York: Raven


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

Press, 1990:11-24. 16. Slevin ML, Plant H, Lynch D, et al. Who should measure quality of life, the doctor or the patient? Br J Cancer 1988;57:109-12. 17. Hays RD, Vickrey BG, Hermann BP, et al. Agreement between self-reports and proxy reports of quality of life in epilepsy patients. Qual Life Res 1995;4:159-68. 18. èÓÔÓ‚‡ å. î‡χÍÓÚÂ‡Ô‚Ú˘ÌË Ë Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡ÒÔÂÍÚË Ì‡ ΘÂÌËÂÚÓ Ò ‡ÌÚË·‡ÍÚÂˇÎÌË Ò‰ÒÚ‚‡ ‚ Å˙΄‡Ëfl. ÑËÒÂÚ‡ˆËfl. 1996, ëÓÙËfl. 19. à‚‡ÌÓ‚‡ Ä, èÂÚÓ‚‡ É, Cost-effectiveness ‡Ì‡ÎËÁ ̇ Ô‡ˆËÂÌÚË Ò ‡ÚÂˇÎ̇ ıËÔÂÚÓÌËfl Ë Ò˙‰Â˜ÌË ÛÒÎÓÊÌÂÌËfl, ÎÂÍÛ‚‡ÌË Ò perindopril. Pharmacia. Vol. LII, book 1-2/2005, 193-7. 20. Ibrahim Al Tamr, ëÚÂÙ‡ÌÓ‚‡ å, 燘ӂÒ͇ Å, ÑËÏËÚÓ‚‡ áÎ, î‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ Ë Í‡˜ÂÒÚ‚Ó Ì‡ ÊË‚ÓÚ Ì‡ ·ÓÎÌËÚÂ Ò ıÓÌ˘ÂÌ ıÂÔ‡ÚËÚ ë. Pharmacia. Vol. LII, book 1-2/2005, 205-9. 21. ÑËÏËÚÓ‚ Ñ. ëÓÍÓÎÓ‚ å. ã˜ÂÌË ̇ Ô‡ˆËÂÌÚË Ò ıÂÔ‡ÚËÚ Ä, Ç Ë ë – Ù‡χÍÓËÍÓÌÓÏ˘ÂÒÍË ‡Ì‡ÎËÁ. Pharmacia. Vol. LII, book 1-2/2005, page 214-8. 22. èÓÔÓ‚ Ñ. î‡χÍÓËÍÓÌÓÏË͇ ‚ ÅÓÎÌ˘̇ ÎÂ͇ÒÚ‚Â̇ ÔÓÎËÚË͇. 1998, 則Ú, ëÓÙËfl. 23. Jacobs P: Behavior of health care costs, in The Economics of Health and Medical Care, ed 3. Gaithersburg, Md., Aspen, 1991, pp 125-131. 24. Heaney DC, Beran RG, Halpern MT. Economics in epilepsy treatment choices: our certain fate? Epilepsia. 2002;43 Suppl 4:32-8. 25. Persson PM, Russom A, Tomson T., Antiepileptic treatment nearly six times more expensive since 1990; Lakartidningen. 2003 Jan 9;100(1-2):42-6. 26. Thomas SV. Money matters in epilepsy; Neurol India. 2000 Dec;48(4):322-9. 27. Arroyo S, Fossas P, Nieto-Barrera M, Salas-Puig X et al. Analysis of cost minimization of monotherapy antiepileptic treatment in patients with recent diagnosed epilepsy : the situation in Spain. Rev Neurol. 2000 Nov 115;31(9):828-32. 28. Heaney DC, Shorvon SD, Sander JW et al. Cost minimization analysis of antiepileptic drugs in newly diagnosed epilepsy in 12 European countries. Epilepsia. 2000;41 Suppl 5:S37-44. 29. Radhakrishnan K, Nayak SD, Kumar SP, Sarma PS. Profile of antiepileptic pharmacotherapy in a tertiary referral center in South India: a pharmacoepidemiologic and pharmacoeconomic study. Epilepsia. 1999 Oct;40(10):14656. 30. Krishnan A, Sahariah S, & Kapoor S, Cost of Epilepsy in Patients Attending a Secondary-level Hospital in India.Epilepsia 2004; 45 (3), 289-291. 31. Hawkins N, Epstein D, Drummond M, Wilby J et al. Assessing the CostEffectiveness of New Pharmaceuticals in Epilepsy in Adults: The Results of

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a Probabilistic Decision Model. Medical Decision Making 2005; 25(5), 493510. 32. Chisholm D. Cost-effectiveness of First-line Antiepileptic Drug Treatments in the Developing World: A Population-level Analysis. Epilepsia 2005;46(5). 33. Shafer P. Improving the quality of life in epilepsy- non-medical issues too often overlooked. Postgraduate medicine online 2002; 1-2. website 34. Thomas SV, Koshy S, Sudhakaran Nair CR, Sarma SP. Frequent seizures and polytherapy can impair quality of life in persons with epilepsy. Neurol India 2005;53:46-50. 35. Devinsky O, Westbrook L, Cramer J, et al. Risk factors for poor health-related quality of life in adolescents with epilepsy. Epilepsia 1999;40(12):171520. 36. Baker GA, Jacoby A, Smith DF, et al. Development of a novel scale to assess life fulfillment as part of the further refinement of a quality-of-life model for epilepsy. Epilepsia 1994;35(3):591-6. 37. Devinsky O, Vickrey BG, Cramer J, et al. Development of the quality of life in epilepsy inventory. Epilepsia 1995;36(11):1089-104. 38. Austin JK, Huster GA, Dunn DW, et al. Adolescents with active or inactive epilepsy or asthma: a comparison of quality of life. Epilepsia 1996;37(12):1228-38. 39. Begley CE, Famulari M, Annegers JF, et al. The cost of epilepsy in the United States: an estimate from population-based clinical and survey data. Epilepsia 2000;41(3):342-51 40. Schachter SC, Shafer PO, Murphy W. The personal impact of seizures: correlations with seizure, frequency, employment, cost of medical care, and satisfaction with physician care. J Epilepsy 1993;6(4):224-7. 41. Wiebe S,, Eliasziw M, & Matijevic S.Changes in Quality of Life in Epilepsy: How Large Must They Be to Be Real?.Epilepsia 2001 42(1), 113-118. 42. Kasteleijn-Nolst Trenite DG, Meijer JW; Discussion of the AED workshop.Pharm World Sci. 1997 Oct;19(5):231-5. 43. Levy P. Economic evaluation of antiepileptic drug therapy: a methodologic review. Epilepsia. 2002 May;43(5):550-8.

é·ÁÓ çÖÇêéçéèêéíÖäñàü ëöë CITICOLINE èêà àëïÖåàóçà åéáöóçà àçëìãíà à óÖêÖèçéåéáöóçà íêÄÇåà è. ëÚ‡ÏÂÌÓ‚‡, å. åË·ÌÓ‚‡, Ñ. Äڇ̇ÒÓ‚‡, å. ꇉ‚‡ ìåÅÄã ◊ñ‡ˈ‡ âÓ‡Ì̇”, äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl, ëÓÙËfl SUMMARY NEUROPROTECTION WITH CITICOLINE IN PATIENTS WITH ISCHEMIC STROKES AND BRAIN INJURIES P. Stamenova, M. Milanova, D. Atanasova, M. Radeva The contemporary therapy of ischemic cerebral stroke is directed to reaper the blood flow (reperfusion) through thrombolysis and protection in the area of penumbra with different neuroprotectors. Around the necrotic area the neuronal death could be prevent using contemporary neuroprotective strategies which reduce the death-rate and the disability for a part of the patients with ischemic cerebral stroke. Citidine 5Diphosphocholine (CDP_Choline or Citicoline) is composed from citidine and choline which are connected through diphosphatic molecular group. Citicoline crosses the bloodbrain barrier and microsoms. It activates the biosynthesis of acetylcholine and structural phospholipids of neuronal membrane and exceeds brain metabolism, modulates the release of glutamate and restores the activity of mitochondric ATPase. Numerous multicentric double-blind, randomized and placebo- controlled clinical studies in ischemic cerebral stroke and brain injury show that citicoline improves the rehabilitation and affects the final functional result, shortens the hospital period. The treatment with citicoline is well endurable without any side effects. KEY WORDS: citicoline, neuroprotection, brain ischemia, brain injury.

ë˙‚ÂÏÂÌ̇ڇ ÚÂ‡ÔËfl ̇ ËÒıÂÏ˘ÌËfl ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ Â Ì‡ÒÓ˜Â̇ Í˙Ï ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Í˙‚ÌËfl ÚÓÍ (ÂÔÂÙÛÁËfl) ˜ÂÁ ÚÓÏ·ÓÎËÁ‡ Ë ÔÓÚÂ͈Ëfl ‚ ÁÓ̇ڇ ̇ penumbra ˜ÂÁ ‡Á΢ÌË Ì‚ÓÌÓÔÓÚÂÍÚÓË. Ç ÓÍÓÎÓ ÌÂÍÓÚ˘̇ڇ ÁÓ̇ Ì‚Ó̇Î̇ڇ ÒÏ˙Ú ÏÓÊ ‰‡ ·˙‰Â Ô‰ÓÚ‚‡ÚÂ̇ ˜ÂÁ ËÁÔÓÎÁ‚‡ÌÂÚÓ Ì‡ Ò˙‚ÂÏÂÌÌË Ì‚ÓÌÓÔÓÚÂÍÚË‚ÌË ÒÚ‡Ú„ËË Ë ÔÓ ÚÓÁË Ì‡˜ËÌ ‰‡ Ò ÒÌËÊË ÒÏ˙ÚÌÓÒÚÚ‡ Ë ËÌ‚‡ÎˉËÁ‡ˆËflÚ‡ ̇ ˜‡ÒÚ ÓÚ ·ÓÎÌËÚÂ Ò ËÒıÂÏ˘ÂÌ ËÌÒÛÎÚ. Citidine 5`-Diphosphocholine (CDPCholine ËÎË Citicoline) Ò Ò˙ÒÚÓË ÓÚ ˆËÚˉËÌ Ë ıÓÎËÌ, ÍÓËÚÓ Ò‡ Ò‚˙Á‡ÌË ˜ÂÁ ‰ËÙÓÒÙ‡ÚÂÌ ÏÓÒÚ. Citicoline ÔÂÏË̇‚‡ Í˙‚ÌÓ ÏÓÁ˙˜Ì‡Ú‡ ·‡ËÂ‡ Ë ‰ÓÒÚË„‡ ñçë, Í˙‰ÂÚÓ Ò ‚Íβ˜‚‡ ‚˙‚ ÙÓÒÙÓÎËÔˉ̇ڇ Ù‡ÍˆËfl ̇ ÏÂÏ·‡Ì‡Ú‡ Ë ÏËÍÓÁÓÏËÚÂ. íÓÈ ‡ÍÚË‚Ë‡ ·ËÓÒËÌÚÂÁ‡Ú‡ ̇ ÒÚÛÍÚÛÌËÚ ÙÓÒÙÓÎËÔË‰Ë Ì‡ Ì‚ÓÌÌËÚ ÏÂÏ·‡ÌË Ë Û‚Â΢‡‚‡ ÏÓÁ˙˜ÌËfl ÏÂÚ‡·ÓÎËÁ˙Ï, ÏÓ‰ÛÎË‡ ÓÒ‚Ó·Óʉ‡‚‡ÌÂÚÓ Ì‡ „ÎÛÚ‡Ï‡Ú Ë ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ ‡ÍÚË‚ÌÓÒÚÚ‡ ̇ ÏËÚÓıÓ̉ˇÎ̇ڇ Äíêase. åÌÓ„Ó·ÓÈÌË ÏÛÎÚˈÂÌÚÓ‚Ë ‰‚ÓÈÌÓ ÒÎÂÔË ‡Ì‰ÓÏËÁË‡ÌË Ë Ô·ˆÂ·ÓÍÓÌÚÓÎË‡ÌË ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl ÔË ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ Ë ˜ÂÂÔÌÓÏÓÁ˙˜Ì‡ Ú‡‚χ ÔÓ͇Á‚‡Ú, ˜Â citicoline ÛÒÍÓfl‚‡ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ, ÔÓ‚ÎËfl‚‡ ÍÓ΢ÂÒÚ‚ÂÌËÚ ̇Û¯ÂÌËfl ̇ Ò˙Á̇ÌËÂÚÓ, ÔÓ‰Ó·fl‚‡ Í‡ÈÌËfl ÙÛÌ͈ËÓ̇ÎÂÌ ÂÁÛÎÚ‡Ú, ÒÍ˙Òfl‚‡ ÔÂËÓ‰‡ ̇ ·ÓÎÌ˘ÌËfl ÔÂÒÚÓÈ. å‰Ë͇ÏÂÌÚ‡  ‰Ó· ÔÓÌÓÒËÏ ·ÂÁ ÒÂËÓÁÌË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË. äãûóéÇà Ñìåà: citicoline, Ì‚ÓÌÓÔÓÚÂ͈Ëfl, ÏÓÁ˙˜Ì‡ ËÒıÂÏËfl, ˜ÂÂÔÌÓÏÓÁ˙˜ÌË Ú‡‚ÏË.


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

åÓÁ˙˜ÌÓÒ˙‰Ó‚ËÚ Á‡·ÓÎfl‚‡ÌËfl Ò‡ ‚‡ÊÂÌ Ï‰ˈËÌÒÍË Ë ÒӈˇÎÂÌ ÔÓ·ÎÂÏ, ÔÓ‡‰Ë ‚ËÒÓ͇ڇ Á‡·Ó΂‡ÂÏÓÒÚ Ë ·ÓÎÂÒÚÌÓÒÚ, ‚ËÒÓ͇ ÒÏ˙ÚÌÓÒÚ Ë ËÌ‚‡ÎˉËÁ‡ˆËfl ‚ ‡Á΢̇ ÒÚÂÔÂÌ Ì‡ ËÁ‡ÁÂÌÓÒÚ ÔË „ÓÎflχ ˜‡ÒÚ ÓÚ ÔÂÊË‚ÂÎËÚÂ. àÒıÂÏ˘ÌËÚ ÏÓÁ˙˜ÌË ËÌÒÛÎÚË Ò‡ ̇È-˜ÂÒÚËÚ ̇Û¯ÂÌËfl ̇ ÏÓÁ˙˜ÌÓÚÓ Í˙‚ÓÓ·‡˘ÂÌË – 80% ÓÚ ‚Ò˘ÍË ËÌÒÛÎÚË. èÓ‰Ó·ÂÌË ÔË Î˜ÂÌË ̇ ËÌÒÛÎÚËÚ ÏÓÊ ‰‡ Ò Ә‡Í‚‡ Ò‡ÏÓ ˜ÂÁ ‰ËÌ ËÌÚ„Ë‡Ì Ë ÍÓÓ‰ËÌË‡Ì ÔÓ‰ıÓ‰ ̇ ÌflÍÓÎÍÓ ÌË‚‡: Ô˙‚˘̇ ÔÓÙË·ÍÚË͇, ‚ÚÓ˘̇ ÔÓÙË·ÍÚË͇, ΘÂÌË ‚ ÓÒÚ‡Ú‡ Ù‡Á‡ Ë ‡‰ÂÍ‚‡Ú̇ Âı‡·ËÎËÚ‡ˆËfl. èË ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ Ô‡ÚÓÙËÁËÓÎӄ˘ÌÓ Ò ‡Á΢‡‚‡Ú ‰‚‡ ÂÚ‡Ô‡: ̇΢ˠ̇ Ò˙‰Ó‚‡ Ô‡ÚÓÎÓ„Ëfl, ÍÓflÚÓ Ô˘ËÌfl‚‡ Ó·ÚÛË‡ÌÂ Ë ‰Û͈Ëfl ̇ Í˙‚ÌËfl ÚÓÍ ‚ ÓÔ‰ÂÎÂÌ Ò˙‰Ó‚ ·‡ÒÂÈÌ Ì‡ ÏÓÁ˙͇ Ë ËÒıÂÏ˘̇ ÌÂÍÓÁ‡ ̇ ÌÂ‚ÌË Ë „ΡÎÌË ÍÎÂÚÍË. íÓ‚‡  ÁÓ̇ڇ ̇ ÌÂÓ·‡ÚËχ ËÒıÂÏËfl, ÍÓflÚÓ Ó·‡˜Â  Á‡Ó·ËÍÓÎÂ̇ ÓÚ ÁÓ̇ Ò ÔÓ-ÎÂ͇ ËÒıÂÏËfl ·ÂÁ ‡Á‚ËÚË ̇ ÌÂÍÓÁ‡, ̇˜Â̇ penumbra. ë˙‚ÂÏÂÌ̇ڇ ÚÂ‡ÔËfl ̇ ËÒıÂÏ˘ÌËfl ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ Â Ì‡ÒÓ˜Â̇ Í˙Ï ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Í˙‚ÌËfl ÚÓÍ (ÂÔÂÙÛÁËfl) ˜ÂÁ ÚÓÏ·ÓÎËÁ‡ Ë ÔÓÚÂ͈Ëfl ‚ ÁÓ̇ڇ ̇ penumbra ˜ÂÁ ‡Á΢ÌË Ì‚ÓÌÓÔÓÚÂÍÚÓË. íÓÏ·ÓÎËÚ˘ÌËÚ Ò‰ÒÚ‚‡ (rt-PA) Ò‡ Ò ‰Ó͇Á‡Ì ÂÙÂÍÚ Ì‡ ‚‡ÒÍÛ·ËÁ‡ˆËfl ̇ Ó·ÚÛË‡ÎËfl Ò˙‰, ÍÓ„‡ÚÓ Ò ÔË·„‡Ú ÔË Ò˙ÓÚ‚ÂÚÌËÚ Ë̉Ë͇ˆËË, ‚ Ô˙‚ËÚ ÚË ˜‡Ò‡ ÓÚ Ì‡˜‡ÎÓÚÓ Ì‡ ËÒıÂÏËflÚ‡. íÓ‚‡  ‰ËÌÒÚ‚Â̇ڇ ÏÂʉÛ̇Ó‰ÌÓ ÔËÂÚ‡ ÚÂ‡ÔËfl ‚ ÓÒÚËfl ÒÚ‡‰ËÈ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ. Ç ÓÍÓÎÓ ÌÂÍÓÚ˘̇ڇ ÁÓ̇ Ì‚Ó̇Î̇ڇ ÒÏ˙Ú ÏÓÊ ‰‡ ·˙‰Â Ô‰ÓÚ‚‡ÚÂ̇ ˜ÂÁ ËÁÔÓÎÁ‚‡ÌÂÚÓ Ì‡ Ò˙‚ÂÏÂÌÌË Ì‚ÓÌÓÔÓÚÂÍÚË‚ÌË ÒÚ‡Ú„ËË Ë ÔÓ ÚÓÁË Ì‡˜ËÌ ‰‡ Ò ÒÌËÊË ÒÏ˙ÚÌÓÒÚÚ‡ Ë ËÌ‚‡ÎˉËÁ‡ˆËflÚ‡ ̇ ˜‡ÒÚ ÓÚ ·ÓÎÌËÚÂ Ò ËÒıÂÏ˘ÂÌ ËÌÒÛÎÚ. ñÂÎÚ‡  ‰‡ Ò ̇χÎË ‚ Á̇˜ËÚÂÎ̇ ÒÚÂÔÂÌ Û‚Âʉ‡˘Ëfl ÂÙÂÍÚ Ì‡ ËÒıÂÏËflÚ‡ ‚˙ıÛ ÏÓÁ˙͇, ÍÓ„‡ÚÓ Ì‚ÓÌÓÔÓÚÂÍÚÓËÚ ҇ ÔËÎÓÊÂÌË Í‡ÚÍÓ ‚ÂÏ ÒΉ ̇˜‡ÎÓÚÓ Ì‡ ÍÎËÌ˘ÌËÚ ÒËÏÔÚÓÏË. àÁ‚ÂÒÚÌË Ò‡ ÏÌÓ„Ó Ì‚ÓÌÓÔÓÚÂÍÚË‚ÌË ‡ÍÚË‚ÌË ÏÓÎÂÍÛÎË, ÍÓËÚÓ Ò‡ ‚˙‚ Ù‡Á‡ III ̇ ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl Á‡ ËÌÒÛÎÚ. ÉÓÎflχ ˜‡ÒÚ ÓÚ Úflı Ò‡ ÔÂÍ˙Ò̇ÚË ÔÓ‡‰Ë ‰‡ÌÌË Á‡ ÎËÔÒ‡ ̇ ÂÙË͇ÒÚÌÓÒÚ ËÎË ÛÒÚ‡ÌÓ‚ÂÌË ÚÓÍÒ˘ÌË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË Ì‡ ωË͇ÏÂÌÚ‡. Citidine 5`-Diposphocholine (CDP-Choline ËÎË Citicoline) Ò Ò˙ÒÚÓË ÓÚ ˆËÚˉËÌ Ë ıÓÎËÌ, ÍÓËÚÓ Ò‡ Ò‚˙Á‡ÌË ˜ÂÁ ‰ËÙÓÒÙ‡ÚÂÌ ÏÓÒÚ. í ҇ ÂÒÚÂÒÚ‚ÂÌ ÏÂʉËÌÂÌ ÔÓ‰ÛÍÚ ÔË ÒËÌÚÂÁ‡Ú‡ ̇ ÙÓÒÙ‡ÚˉËÎıÓÎËÌ (PC). ÖÍÁÓ„ÂÌÌËflÚ CDP-choline Ò ıˉÓÎËÁË‡ Ë ‡·ÒÓ·Ë‡ ͇ÚÓ ˆËÚˉËÌ Ë ıÓÎËÌ (48) Ë Ò ÂÒËÌÚÂÁË‡ ‚ Ó„‡ÌËÁχ. ljÌ˙Ê ‡·ÒÓ·Ë‡Ì Citicoline Ò ‡ÁÔÓÒÚ‡Ìfl‚‡ ¯ËÓÍÓ ‚ Ó„‡ÌËÁχ, ÔÂÏË̇‚‡ Í˙‚ÌÓ ÏÓÁ˙˜Ì‡Ú‡ ·‡ËÂ‡ Ë ‰ÓÒÚË„‡ ñÂÌÚ‡Î̇ڇ çÂ‚̇ ëËÒÚÂχ (ñçë), Í˙‰ÂÚÓ Ò ‚Íβ˜‚‡ ‚˙‚ ÙÓÒÙÓÎËÔˉ̇ڇ Ù‡ÍˆËfl ̇ ÏÂÏ·‡Ì‡Ú‡ Ë ÏËÍÓÁÓÏËÚ (10,36,50). Citicoline ‡ÍÚË‚Ë‡ ·ËÓÒËÌÚÂÁ‡Ú‡ ̇ ÒÚÛÍÚÛÌËÚ ÙÓÒÙÓÎËÔË‰Ë Ì‡ Ì‚ÓÌÌËÚ ÏÂÏ·‡ÌË (6), Û‚Â΢‡‚‡ ÏÓÁ˙˜ÌËfl ÏÂÚ‡·ÓÎËÁ˙Ï (26) Ë ‰ÂÈÒÚ‚‡ ‚˙ıÛ ÍÓ̈ÂÌÚ‡ˆËflÚ‡ ̇ ‡Á΢ÌË Ì‚ÓÚ‡ÌÒÏËÚÂË Í‡ÚÓ: ‡ˆÂÚËÎıÓÎËÌ, ‰ÓÔ‡ÏËÌ Ë ÌÓÂÔËÌÂÙËÌ (22,38). íÓÈ ÏÓ‰ÛÎË‡ ÓÒ‚Ó·Óʉ‡‚‡ÌÂÚÓ Ì‡ „ÎÛÚ‡Ï‡Ú (5,7). Citicoline ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ ‡ÍÚË‚ÌÓÒÚÚ‡ ̇ ÏËÚÓıÓ̉ˇÎ̇ڇ ATPase Ë ÏÂÏ·‡Ì̇ڇ N‡+/K+ ATPase (47) (ÙË„.1). íÓÈ ËÌıË·Ë‡ ‡ÍÚË‚Ë‡ÌÂÚÓ Ì‡ ÙÓÒÙÓÎËÔ‡ÁË (9,42,54) Ë ÛÒÍÓfl‚‡ ‡·ÒÓ·ˆËflÚ‡ ̇ ÏÓÁ˙˜ÌËflÚ ÓÚÓÍ (11,14) (ÙË„.1). èÓ ÚÓÁË Ì‡˜ËÌ Ò ÒÌËʇ‚‡ Ë ËÌÙ‡ÍÚÌËfl Ó·ÂÏ (ÙË„. 2). CDP-Choline ÒÎÛÊË Ë Í‡ÚÓ ıÓÎËÌÓ‚ ‰ÓÌÓ ÔË ÒËÌÚÂÁ‡Ú‡ ̇ Ì‚ÓÚ‡ÌÒÏËÚÂ‡ ‡ˆÂÚËÎıÓÎËÌ (2). èËÂχ ÒÂ, ˜Â ͇ÚÓ ÏÂʉËÌÂÌ ÔÓ‰ÛÍÚ ‚ ÒËÌÚÂÁ‡Ú‡ ̇ êë, CDPCholine ÍÓË„Ë‡ ÏÂÏ·‡ÌÌËÚ ۂÂʉ‡ÌËfl Ë ·Î‡„ÓÔËflÚÌÓ ÔÓ‚ÎËfl‚‡ ñçë ÔË Ú‡‚ÏË, ÏÓÁ˙˜ÌË ËÌÒÛÎÚË Ë ‰.

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Citicoline  ÏÂʉÛ̇Ó‰ÌÓÚÓ ÌÂÔ‡ÚÂÌÚÌÓ Ì‡ËÏÂÌÓ‚‡ÌË ̇ CDP-Choline „ËÒÚË‡ÌÓ Í‡ÚÓ Ï‰Ë͇ÏÂÌÚ ‚ üÔÓÌËfl, àÒÔ‡ÌËfl, î‡ÌˆËfl, àÚ‡ÎËfl, èÓÚÛ„‡ÎËfl Ë ÏÌÓ„Ó ‰Û„Ë ÒÚ‡ÌË, ‚ÍÎ. Å˙΄‡Ëfl Ë Í‡ÚÓ éíë ÔÓ‰ÛÍÚ ‚ ëÄô. CDP-Choline Ô˙‚Ó̇˜‡ÎÌÓ Â ‡Á‡·ÓÚÂÌ Á‡ ΘÂÌË ̇ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ ÓÚ Ferrer International, S. A. (ŇÒÂÎÓ̇, àÒÔ‡ÌËfl). èÓ-Í˙ÒÌÓ Á‡ÔÓ˜‚‡Ú ÔÓÛ˜‚‡ÌËfl Á‡ ΘÂÌË ̇ ·ÓÎÂÒÚÚ‡ ̇ ÄΈı‡ÈÏÂ Ë è‡ÍËÌÒÓÌÓ‚‡Ú‡ ·ÓÎÂÒÚ (8). CDP-Choline  ‰ËÌÒÚ‚ÂÌÓÚÓ Ì ÍÒÂÌÓ·ËÓÚ˘ÌÓ ‚¢ÂÒÚ‚Ó ·ÂÁ ÒÚ‡Ì˘ÌË ÂÙÂÍÚË. ÖÌÂ„ËÈÌËÚ ÌÛÊ‰Ë Ì‡ ÏÓÁ˙͇ Ò ۉӂÓÎÂÚ‚Ófl‚‡Ú ˜ÂÁ ‡ÂÓ·ÌÓ ‡Á„‡Ê‰‡Ì ̇ „βÍÓÁ‡ Á‡ ÙÓÒÙÓË·ˆËfl ̇ ÄÑî ‰Ó Äíî. åÓÁ˙˜Ì‡Ú‡ ËÒıÂÏËfl ‚Ó‰Ë ‰Ó flÁ͇ Á‡„Û·‡ ̇ Äíî, ÍÓÂÚÓ Ò˙Á‰‡‚‡ ÛÒÎÓ‚Ëfl Á‡ ÌÂÍÓÌÚÓÎË‡ÌÓ ÔÂÏË̇‚‡Ì ̇ ÈÓÌË ÔÂÁ ÍÎÂÚ˙˜Ì‡Ú‡ ÏÂÏ·‡Ì‡, ‰ÂÔÓÎflËÁ‡ˆËfl Ë ÓÒ‚Ó·Óʉ‡‚‡Ì ̇ Ì‚ÓÚ‡ÌÒÏËÚÂËÚ „ÎÛÚ‡Ï‡Ú Ë ‰ÓÔ‡ÏËÌ (52). ÖÍÒˆÂÒË‚ÌÓÚÓ ÓÒ‚Ó·Óʉ‡‚‡Ì ̇ „ÎÛÚ‡Ï‡Ú Ë ‡ÍÚË‚Ë‡Ì ̇ „ÎÛڇχÚÌËÚ ˆÂÔÚÓË ‚Ó‰Ë ‰Ó ‡ÍÚË‚Ë‡Ì ̇ ÙÓÒÙÓÎËÔ‡ÁË, ıˉÓÎËÁ‡ ̇ ÙÓÒÙÓÎËÔË‰Ë Ë ÓÒ‚Ó·Óʉ‡‚‡Ì ̇ ‡‡ıˉÓÌÓ‚‡ ÍËÒÂÎË̇ (2). íÓ‚‡  Ô‰ÔÓÒÚ‡‚͇ Á‡ ‡ÔÓÔÚÓÁ‡ Ë ‡Á‚ËÚË ̇ ÍÎÂÚ˙˜Ì‡ ÒÏ˙Ú - ÌÂÍÓÁ‡ (39). èË ÛÒÎÓ‚ËÂ, ˜Â  ÂÒÚÂÒÚ‚ÂÌ ÒÚÛÍÚÓÂÌ ÍÓÏÔÓÌÂÌÚ Ì‡ ÏÂÏ·‡Ì‡Ú‡, êë  ËÁÚÓ˜ÌËÍ Ì‡ ·ËÓ‡ÍÚË‚ÌË ÎËÔË‰Ë Í‡ÚÓ: ÙÓÒÙ‡Úˉ‡ÁË, 1,2-‰Ë‡ˆË΄ÎˈÂÓÎ, ‡‡ıˉÓÌÓ‚‡ ÍËÒÂÎË̇ Ë ‰. (17). ïˉÓÎËÁ‡Ú‡ ̇ êë Ë„‡Â ‚‡Ê̇ ÓÎfl ‚ ÔÂ̇ÒflÌÂÚÓ Ì‡ Ò˄̇ÎË ˜ÂÁ ‡Á΢ÌË ‚˙Á·Û‰ËÚÂÎË ‚Íβ˜ËÚÂÎÌÓ ˆËÚÓÍËÌË (28). êë ÏÓÊ ‰‡ ·˙‰Â ıˉÓÎËÁË‡Ì (24,53) ÓÚ êë-ÙÓÒÙÓÎËÔ‡Á‡ ë (êLë) (35), êë-ÙÓÒÙÓÎËÔ‡Á‡ D (PLD) (27) ËÎË PLA2 (49). ë˙˘ÂÒÚ‚Û‚‡Ú ‰Ó͇Á‡ÚÂÎÒÚ‚‡, ˜Â PLA2 Ò ‡ÍÚË‚Ë‡ ÔË ÔÂıӉ̇ ËÒıÂÏËfl Ë ‰ÓÔË̇Òfl Á‡ Ì‚Ó̇ÎÌÓÚÓ Û‚Âʉ‡Ì (1,3). ã˜ÂÌËÂÚÓ Ò CDP-Choline ÒË„ÌËÙË͇ÌÚÌÓ ‰ۈË‡ ‡ÍÚË‚ÌÓÒÚÚ‡ ̇ PLA2 ‚ ÏÂÏ·‡ÌÌËÚÂ Ë ÏËÚÓıÓ̉ˇÎÌË Ù‡ÍˆËË. In vitro CDP-Choline Ë Ì„ӂËÚ ÍÓÏÔÓÌÂÌÚË (ˆËÚˉËÌ Ë ıÓÎËÌ) ÌflÏ‡Ú ÂÙÂÍÚ ‚˙ıÛ ‡ÍÚË‚ÌÓÒÚÚ‡ ̇ PLA2, Ú.Â. ÚÓÈ Ì  PLA2 ËÌıË·ËÚÓ (4). é·‡ÁÛ‚‡ÌÂÚÓ Ì‡ Ò‚Ó·Ó‰ÌË ‡‰Ë͇ÎË Ë ÓÍËÒÎÂÌËÂÚÓ Ì‡ ·ËÓÎӄ˘ÌË ÏÓÎÂÍÛÎË Â ‰Ó· ÔÓÁÌ‡Ú ÏÂı‡ÌËÁ˙Ï Ì‡ Ú˙Í˙Ì̇ Û‚‰‡ ÔË ËÒıÂÏËfl/ÂÔÂÙÛÁËfl (29,30). ê‡ÍÚË‚ÌË ÍËÒÎÓÓ‰ÌË ˜‡ÒÚËˆË ‰Ó‚Âʉ‡Ú ‰Ó ÎËÔˉ̇ ÔÂÓÍÒˉ‡ˆËfl Ë Ó·‡ÁÛ‚‡Ì ̇ χÎÓ̉ˇΉÂıˉ (MDA), 4-ıˉÓÍÒËÌÓÌÂ̇Π(HNE) Ë ‡ÍÓÎÂËÌ (40,55). HNE Ë ‡ÍÓÎÂËÌ Ô‰ËÁ‚ËÍ‚‡Ú Ì‚Ó̇Î̇ ‡ÔÓÔÚÓÁ‡ (40,55). CDP-choline ÒË„ÌËÙË͇ÌÚÌÓ Ì‡Ï‡Îfl‚‡ Ó·‡ÁÛ‚‡ÌÂÚÓ Ì‡ ÍËÒÎÓÓ‰ÌË ‡‰Ë͇ÎË Ë Ì‡ MDA ÔË ËÒıÂÏËfl (1,4). PLA2 ÓÒ‚Ó·Óʉ‡‚‡ Ò‚Ó·Ó‰ÌË Ï‡ÒÚÌË ÍËÒÂÎËÌË, ‚ ÚÓ‚‡ ˜ËÒÎÓ Ë ‡‡ıˉÓÌÓ‚‡ ÍËÒÂÎË̇ ÓÚ ÏÂÏ·‡ÌÌËÚ ÙÓÒÙÓÎËÔË‰Ë (1,27,45) (ÙË„.3). ç‡Ï‡ÎÂ̇ڇ ÔÓ‰Û͈Ëfl ̇ ıˉÓÍÒËÎÌË ‡‰Ë͇ÎË ÔË ÔÂıӉ̇ ÏÓÁ˙˜Ì‡ ËÒıÂÏËfl ÒΉ ÔËÎÓÊÂÌË ̇ CDP-choline ̇È-‚ÂÓflÚÌÓ Ò ‰˙ÎÊË Ì‡ ÔÓ‰ÚËÒ͇Ì ̇ ‡ÍÚË‚ÌÌÓÒÚÚ‡ ̇ PLA2. C˙ÒÚ‡‚͇ڇ choline ÏÓÊ Ò˙˘Ó ڇ͇ ‰‡ Ò ‡ˆÂÚËÎË‡ ‚ Ì‚ÓÚ‡ÌÒÏËÚÂ‡ acetylholine ËÎË ‰‡ Ò ÏÂÚ‡·ÓÎËÁË‡ ‰Ó betain, ÍÓÈÚÓ Â ËÁÚÓ˜ÌËÍ Ì‡ ÏÂÚËÎÓ‚‡ „ÛÔ‡ ‚ ÒËÌÚÂÁ‡ ̇ ̇ methioneine Ë S-adenosyl-L-methionine, ÍÓÈÚÓ ÏÓÊ ‰‡ ÏÂÚ‡·ÓÎËÁË‡ ÔÓ-̇ڇÚ˙Í ‰Ó glutathione. èÂÁ ÔÓÒΉÌËÚ 35 „Ó‰ËÌË Citicoline e Ô‰ÏÂÚ Ì‡ ̇ۘÌÓ-ËÁÒΉӂ‡ÚÂÎÒ͇ڇ ‡·ÓÚ‡ ̇ ÏÌÓ„Ó ÏÂʉÛ̇Ó‰ÌË ÂÍËÔË ‚ àÒÔ‡ÌËfl, î‡ÌˆËfl, àÚ‡ÎËfl, ÉÂχÌËfl, üÔÓÌËfl, ëÄô Ë èÓÚÛ„‡ÎËfl. éÚ „ÓÎflÏ ·ÓÈ Ô‰ÍÎËÌ˘ÌË Ë ÍÎËÌ˘ÌË ËÁÒΉ‚‡ÌËfl Ò‡ Ò˙·‡ÌË ÏÌÓ„Ó ÂÍÒÔÂËÏÂÌÚ‡ÎÌË Ë ÍÎËÌ˘ÌË ‰‡ÌÌË ‚ Ú‡ÁË Ì‡ÒÓ͇, ÍÓËÚÓ Ò‡ ÔÛ·ÎËÍÛ‚‡ÌË ‚ ̇‰ 400 ‡‚ÚÓËÚÂÚÌË ÏÂʉÛ̇Ó‰ÌË Ì‡Û˜ÌË ÒÔËÒ‡ÌËfl. 1. êÂÁÛÎÚ‡ÚË ÓÚ ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl ÔË ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ éÚ 1980 „Ó‰Ë̇ ‰Ó Ò„‡ Ò‡ Ôӂ‰ÂÌË 13 ÍÎËÌ˘ÌË ÔÓ-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

Û˜‚‡ÌËfl Á‡ ÛÒÚ‡ÌÓ‚fl‚‡Ì ̇ ÂÙÂÍÚË‚ÌÓÒÚÚ‡ Ë ·ÂÁÓÔ‡ÒÚÌÓÒÚÚ‡ ̇ CDP-Choline ÔË ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ (‰Â‚ÂÚ ‚ Ö‚ÓÔ‡ Ë üÔÓÌËfl Ë ˜ÂÚËË ‚ ëÄô) (2). Ö‚ÓÔÂÈÒÍËÚ ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl ÔÓ͇Á‚‡Ú, ˜Â CDP-Choline ‰ÓÔË̇Òfl Á‡ ÔÓ-‡ÌÌÓÚÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ó„ÌË˘Ì‡Ú‡ Ì‚ÓÎӄ˘̇ ÒËÏÔÚÓχÚË͇ Ë ÍÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË. Ç „ÓÎflÏÓ ÏÛÎÚˈÂÌÚÓ‚Ó ‡Ì‰ÓÏËÁË‡ÌÓ ‰‚ÓÈÌÓ ÒÎflÔÓ Ô·ˆÂ·Ó ÍÓÌÚÓÎË‡ÌÓ ÔÓÛ˜‚‡Ì ‚ üÔÓÌËfl (51)  ÛÒÚ‡ÌÓ‚ÂÌÓ, ˜Â CDP-Choline ÔÓ‰Ó·fl‚‡ Ò˙ÒÚÓflÌËÂÚÓ Ì‡ ·ÓÎÌËÚ ÓÚ˜ÂÚÂÌÓ ˜ÂÁ Òڇ̉‡ÚÌË Ò͇ÎË: Conscience, Global improvement rate, Global usefulness rate (ÙË„.4). äÎËÌ˘ÌÓÚÓ ÔÓÛ˜‚‡Ì  ËÁ‚˙¯ÂÌÓ ÔË 272 ·ÓÎÌË Ò ÏÓÁ˙˜ÂÌ ËÌÙ‡ÍÚ, ͇ÚÓ ÔË 133 ÓÚ Úflı  ÔË·„‡Ì Citicoline Ë ÔË 139 – placebo. ã˜ÂÌËÂÚÓ Â ÔÓ‚Âʉ‡ÌÓ ‚ ÔÓ‰˙ÎÊÂÌË ̇ 14 ‰ÌË. ìÒÚ‡ÌÓ‚ÂÌË Ò‡ ÒÚ‡ÚËÒÚ˘ÂÒÍË Á̇˜ËÏË ‡ÁÎËÍË ‚ „ÛÔ‡Ú‡ Ò˙Ò Citicoline Ë placebo „ÛÔ‡Ú‡ ‚˙‚ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ì‡ ÌË‚ÓÚÓ Ì‡ Ò˙Á̇ÌËÂÚÓ (Ò˙ÓÚ‚ÂÚÌÓ 51% Ë 33%,  < 0.05), ÒÚÂÔÂÌÚ‡ ̇ Ó·˘ÓÚÓ ÔÓ‰Ó·ÂÌË ‚ Ì‚ÓÎӄ˘ÌËfl ÒÚ‡ÚÛÒ (Ò˙ÓÚ‚ÂÚÌÓ 52% Ë 26%,  < 0.01) Ë ÒÚÂÔÂÌÚ‡ ̇ Ó·˘‡Ú‡ ÔÓÎÂÁÌÓÒÚ (Ò˙ÓÚ‚ÂÚÌÓ 47% Ë 24%,  < 0.001). ç ҇ ÛÒÚ‡ÌÓ‚ÂÌË ÒÂËÓÁÌË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË Ò‚˙Á‡ÌË Ò Î˜ÂÌËÂÚÓ. Ç ëÄô Ò‡ Ôӂ‰ÂÌË ˜ÂÚËË „ÓÎÂÏË ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl ÓÚ 1997 ‰Ó 2000 „Ó‰. Ò˙Ò CDP-Choline (18). Ç Ô˙‚ÓÚÓ ÔÓÛ˜‚‡Ì  ÛÒÚ‡ÌÓ‚ÂÌÓ, ˜Â CDP-Choline ÔÓ‰Ó·fl‚‡ ÙÛÌ͈ËÓ̇ÎÌÓÚÓ Ò˙ÒÚÓflÌËÂ Ë ‰ۈË‡ Ì‚ÓÎӄ˘ÌËfl ‰ÂÙˈËÚ. Ç ÒΉ‚‡˘Ë ‰‚ ÔÓÛ˜‚‡ÌËfl, Ó·‡˜Â Ì Ò ÛÒÚ‡ÌÓ‚fl‚‡Ú ۷‰ËÚÂÎÌË ‰‡ÌÌË Á‡ Ú‡ÍÓ‚‡ ÔÓ‰Ó·ÂÌËÂ. èË ËÁ‚˙¯ÂÌËfl post-hoc ‡Ì‡ÎËÁ Ò ÓÚ˜ËÚ‡, ˜Â CDP-Choline Ëχ ÔÓ‰Ó·fl‚‡˘ ÂÙÂÍÚ Ò‡ÏÓ ‚ ÔÓ‰„ÛÔ‡Ú‡ ̇ Ò‰ÌÓÚÂÊÍË Ë ÚÂÊÍË ËÒıÂÏ˘ÌË ÏÓÁ˙˜ÌË ËÌÒÛÎÚË. èÂÁ 2000 „Ó‰Ë̇  ËÁ‚˙¯ÂÌ Ó·Ó·˘ÂÌ ‡Ì‡ÎËÁ ̇ ‰‡ÌÌËÚ ̇ 1652 Ô‡ˆËÂÌÚË, ÍÓËÚÓ Ò‡ ‚ÁÂÎË Û˜‡ÒÚË ‚ 4 ÔÓÛ˜‚‡ÌËfl Ôӂ‰ÂÌË ‚ ëÄô (15,16,25,57). è‰‚‡ËÚÂÎÌËflÚ ‰ËÁ‡ÈÌ Ì‡ ÔÓÚÓÍÓ· ‚Íβ˜‚‡ ÓˆÂÌ͇ ̇ ÂÙÂÍÚ‡ ÔË Ô‡ˆËÂÌÚË Ò ÛÏÂÂÌÓ ÚÂÊ˙Í Ë ÚÂÊ˙Í ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ, ÓˆÂÌfl‚‡Ì ˜ÂÁ Ò͇ÎËÚ NIHSS Ë Rankin. éÚ˜ÂÚÂÌ Â ÂÁÛÎÚ‡Ú˙Ú Á‡ Ô˙ÎÌÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ ·ÓÎÌËÚ Á‡ 3 ÏÂÒˆ‡ (ÙË„.5). íÓÁË ÔÓÚÓÍÓÎ Â Ó‰Ó·ÂÌ ÓÚ ÌÂÁ‡‚ËÒËχ ËÌÒÚËÚÛˆËfl. ëΉ ÔË·„‡Ì ̇ ÔÓÚÓÍÓ·, „ÛÔ‡Ú‡  ̇χÎÂ̇ ‰Ó 1372 Ô‡ˆËÂÌÚË, ÍÓËÚÓ ÓÚ„Ó‚‡flÚ Ì‡ ÛÒÚ‡ÌÓ‚ÂÌËÚ ÍËÚÂËË. éˆÂÌ͇ڇ ̇ ÂÙË͇ÒÌÓÒÚÚ‡ ̇ citicoline Á‡ ÚËÚ ËÁÔÓÎÁ‚‡ÌË ‰ÓÁË (500, 1000 Ë 2000 mg)  ÔÓ͇Á‡Î‡ Ô˙ÎÌÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ÔË 15.2% ÓÚ Ô‡ˆËÂÌÚËÚÂ, ÎÂÍÛ‚‡ÌË Ò˙Ò citicoline, ‚ Ò‡‚ÌÂÌËÂ Ò 12.5% ÓÚ placebo „ÛÔ‡Ú‡ Ë Â ‰Ó͇Á‡ÌÓ, ˜Â ̇È-ÂÙËÍÚ˂̇ڇ ‰Ì‚̇ ‰ÓÁ‡  2000 mg (= 0.0045). ìÒÚ‡ÌÓ‚Â̇  ·ÂÁÓÔ‡ÒÌÓÒÚÚ‡ ̇ ÎÂ͇ÒÚ‚ÓÚÓ. ç ҇ „ËÒÚË‡ÌË ÒÂËÓÁÌË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË. é·Ó·˘ÂÌË ‰‡ÌÌË ÓÚ DW-MRI ËÁÒΉ‚‡ÌËfl (diffusionweighted magnetic resonance imaging) ̇ ‰‚ ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl, ÔÓ͇Á‚‡Ú ÒË„ÌËÙË͇ÌÚ̇ ‰ÓÁÓ-Á‡‚ËÒËχ ‰Û͈Ëfl ̇ ÔÓˆÂÌÚ̇ڇ ÔÓÏfl̇ ‚ Ó·Âχ ̇ ÏÓÁ˙˜ÌËÚ ÎÂÁËË (56) (ÙË„. 6). 2. êÂÁÛÎÚ‡ÚË ÓÚ ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl ÔË Ô‡ˆËÂÌÚË Ò ˜ÂÂÔÌÓ-ÏÓÁ˙˜Ì‡ Ú‡‚χ äÎËÌ˘ÌËÚ ÔÓÛ˜‚‡ÌËfl Á‡ ÔËÎÓÊÂÌËÂÚÓ Ì‡ Citicoline ÔË Ô‡ˆËÂÌÚË Ò ˜ÂÂÔÌÓ-ÏÓÁ˙˜Ì‡ Ú‡‚χ Á‡ÔÓ˜‚‡Ú Ӣ ÔÂÁ 1967. ᇠÔÂËÓ‰‡ 1976 – 2000 „. Ò‡ Ôӂ‰ÂÌË Ì‡‰ 15 ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl, ‚ ÍÓËÚÓ Ò‡ ‚Íβ˜ÂÌË Ôӂ˜ ÓÚ 1600 Ô‡ˆËÂÌÚË ÓÚ àÒÔ‡ÌËfl, àÚ‡ÎËfl, î‡ÌˆËfl Ë üÔÓÌËfl. ëΉ ÔËÎÓÊÂÌË ̇ Citicoline ‚ ‰ÓÁËӂ͇ 500-1000 Ï„/‰ÂÌ Ò‡ ÛÒÚ‡ÌÓ‚ÂÌË ÒΉÌËÚ ÔÓÎÓÊËÚÂÎÌÌË ÂÁÛÎÚ‡ÚË ÔË Î˜ÂÌËÂÚÓ Ì‡ ˜ÂÂÔÌÓ-ÏÓÁ˙˜Ì‡ Ú‡‚χ ÒÔÓ‰ ‡Á΢ÌËÚ ‡‚ÚÓË: - ωË͇ÏÂÌÚ‡  ÂÙÂÍÚË‚ÂÌ Á‡ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ì‚ÓÎӄ˘ÌËÚ ÍÎËÌ˘ÌË ÒËÏÔÚÓÏË Ë Ì‡ Ò˙Á̇ÌËÂÚÓ ÔË

71

70% ÓÚ ÒÎÛ˜‡ËÚ (41); - ÔÓ‰Ó·fl‚‡ ÒÚÂÔÂÌÚ‡ ̇ Ò˙Á̇ÌËÂÚÓ ÔË Ô‡ˆËÂÌÚË ÒΉ ˜ÂÂÔÌÓ-ÏÓÁ˙˜Ì‡ Ú‡‚χ (20); - Ô‰ËÁ‚ËÍ‚‡ ‡ÌÌÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ò˙Á̇ÌËÂÚÓ Ë ÔÓ‰Ó·fl‚‡ ÍÎËÌ˘ÌËÚÂ Ë ÖÖÉ ÂÁÛÎÚ‡ÚË Ì‡ Ô‡ˆËÂÌÚËÚ (23); - Á̇˜ËÚÂÎÌÓ ÒÍ˙Òfl‚‡ ÍÓχÚÓÁÌËfl ÔÂËÓ‰ Ë ÛÒÍÓfl‚‡ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ì‡ ÏÓÚÓÌËfl ‰ÂÙˈËÚ Ë ÔÓıӉ͇ڇ (46); - ̇χÎfl‚‡ ‚ÂÏÂÚÓ ÌÂÓ·ıÓ‰ËÏÓ Á‡ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ò˙Á̇ÌËÂÚÓ Ë Ó„ÌˢÌËfl Ì‚ÓÎӄ˘ÂÌ ‰ÂÙˈËÚ ÔË Ô‡ˆËÂÌÚË Ò ÓÒÚ‡ óåí (ÙË„.7). - Á̇˜ËÚÂÎÌÓ ÔÓ‰Ó·fl‚‡ ÔÂÊË‚flÂÏÓÒÚÚ‡, Ì‚ÓÎӄ˘ÌËfl ‰ÂÙˈËÚ Ë ÒÚÂÔÂÌÚ‡ ̇ Ò˙Á̇ÌËÂÚÓ (31); - ̇χÎfl‚‡ ÔÓÒÚ-Ú‡‚χÚ˘̇ڇ ÍÓχ Ë ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚÚ‡ ̇ Ì‚ÓÎӄ˘ÌËÚÂ Ë ÔÒËıÓÎӄ˘ÌËÚ ÔÓÒÎÂ‰ËˆË (19); - ÔÓ-ÂÙÂÍÚË‚ÂÌ ÔË ÔÓ‰Ó·ÂÌË ̇ Ô‡‡ÏÂÚËÚ ҂˙Á‡ÌË Ò ËÁÔ˙ÎÌËÚÂÎÒÍËfl Ù‡ÍÚÓ, ÓÚÍÓÎÍÓÚÓ Ò ÚÂÁË, Ò‚˙Á‡ÌË Ò ‚Â·‡ÎÌËfl Ù‡ÍÚÓ (43); - Ó·˘ÓÚÓ ÔÓ‰Ó·ÂÌË ÔË ‚Ò˘ÍË Ô‡ˆËÂÌÚË Ò ҂˙Á‚‡ Ò Î˜ÂÌËÂÚÓ Ò˙Ò Citicoline. ç  ÓÚ˜ÂÚÂÌÓ ÔÓ‚ÎËfl‚‡Ì ̇ ÒÏ˙ÚÌÓÒÚÚ‡ Ë ˜ÂÒÚÓÚ‡Ú‡ ̇ ‚„ÂÚ‡ÚË‚ÌÓÚÓ Ò˙ÒÚÓflÌË (44); - ÔÓ‰Ó·fl‚‡ „ÎÓ·‡ÎÌËfl ÂÁÛÎÚ‡Ú Ì‡ Ô‡ˆËÂÌÚËÚÂ; Ëχ ÚẨÂ̈Ëfl Í˙Ï ÔÓ-„ÓÎflÏÓ ÔÓ‰Ó·ÂÌË ̇ ÏÓÚÓÌËÚÂ, ÍÓ„ÌËÚË‚ÌË Ë ÔÒËı˘ÌËÚ ËÁÏÂÌÂÌËfl. ë˙˘Ó ڇ͇ ‚Ó‰Ë Ë ‰Ó ÒÍ˙Òfl‚‡Ì ̇ ·ÓÎÌ˘ÌËfl ÔÂÒÚÓÈ (12); - Ô‰ËÁ‚ËÍ‚‡ Á̇˜ËÚÂÎ̇ ‰Û͈Ëfl ̇ ÔÓÒÚ-Ú‡‚χÚ˘ÂÌËfl ÒË̉ÓÏ Ë ‚Ó‰Ë ‰Ó Á̇˜ËÚÂÎÌÓ ÔÓ‰Ó·ÂÌË ‚ ‡ÁÔÓÁ̇‚‡ÚÂÎ̇ڇ Ô‡ÏÂÚ ÒÔflÏÓ „ÛÔ‡Ú‡ ̇ placebo (34); - ÛÒÍÓfl‚‡ ̇χÎfl‚‡ÌÂÚÓ Ì‡ ÏÓÁ˙˜ÌËfl ÓÚÓÍ (37) (ÙË„.8); - Ëχ ‡ÙËÌËÚÂÚ Í˙Ï ÏÓÁ˙˜ÌËÚ ÁÓÌË ‡ÒÓˆËË‡ÌË Ò Ô‡ÏÂÚÚ‡, ÌÓχÎËÁË‡ Í˙‚ÌËfl ÚÓÍ ‚ ıËÔÓÔÂÙÛÁËÓÌÌËfl ÚÂÏÔÓÓ-·‡Á‡ÎÂÌ „ËÓÌ Ë Ò˙Á‰‡‚‡ ÛÒÎÓ‚Ëfl Á‡ ÔÓ-ÂÙÂÍÚË‚ÌÓ Ì‚ÓÔÒËıÓÎӄ˘ÌÓÚÓ Ó·Û˜ÂÌË (33). èӂ‰ÂÌË Ò‡ ‰‚ Ò‡‚ÌËÚÂÎÌË ËÁÒΉ‚‡ÌËfl Á‡ ‰Ó͇Á‚‡Ì ̇ ÍÎËÌ˘̇ڇ ÂÙË͇ÒÌÓÒÚ Ì‡ Citicoline ÒÔflÏÓ ‰Û„Ë ÎÂ͇ÒÚ‚‡. Ç ‰‚ÓÈÌÓ-ÒÎflÔÓ ÍÓÌÚÓÎË‡ÌÓ ÔÓÛ˜‚‡Ì ̇ Lecuire Ë Duplay 1982 (31) Ò Ò‡‚Ìfl‚‡ ÂÙÂÍÚ‡ ÓÚ Citicoline 750 Ï„/‰ÂÌ ËÌÚ‡‚ÂÌÓÁÌÓ, Ò ËÌÚ‡‚ÂÌÓÁÂÌ meclofenoxatte 3„/‰ÂÌ ‚ „ÛÔ‡ ÓÚ 25 Ô‡ˆËÂÌÚË. Ä̇ÎËÁ˙Ú Ì‡ ÂÁÛÎÚ‡ÚËÚ ÔÓ͇Á‚‡ Á̇˜ËÚÂÎÌÓ ÔÓ‰Ó·ÂÌË ‚ „ÛÔ‡Ú‡ ÎÂÍÛ‚‡Ì‡ Ò˙Ò Citicoline: ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ò˙Á̇ÌËÂÚÓ, ÏÓ‰ËÙË͇ˆËfl ̇ EEG Ë ÙÛÌ͈ËÓ̇ÎÌÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂ. ë‰̇ڇ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚ Ì‡ ÍÓχڇ  ·Ë· 10 ‰ÌË ‚ „ÛÔ‡Ú‡ Ò˙Ò Citicoline Ë 20 ‰ÌË ÔË „ÛÔ‡Ú‡ Ò meclofenoxatte. ëΉ 10-ÚËfl ‰ÂÌ Ò‡ ̇·Î˛‰‡‚‡ÌË ÔÓ‰Ó·ÂÌËfl ‚ EEG ÔÓÏÂÌËÚ ÔË 50% ÓÚ Ô‡ˆËÂÌÚËÚÂ, ÎÂÍÛ‚‡ÌË Ò Citicoline ÒÂ˘Û 18% ÓÚ ‰Û„‡Ú‡ „ÛÔ‡. Ç Á‡Íβ˜ÂÌË ‡‚ÚÓËÚ ÔÓ‰˜ÂÚ‡‚‡Ú, ˜Â ΘÂÌËÂÚÓ Ò˙Ò Citicoline ‚Ó‰Ë ‰Ó ÔÓ-‰Ó·˙ ÂÁÛÎÚ‡Ú ÓÚÌÓÒÌÓ ÛÒÍÓfl‚‡Ì ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ì‡ Ò˙Á̇ÌËÂÚÓ, Ò‚˙Á‡ÌÓ Ë Ò ÔÓ‰Ó·fl‚‡Ì ̇ EEG ÔÓÏÂÌËÚÂ. Lecuire 1985 (32)  ÔÓ‚ÂÎ ‰‚ÓÈÌÓ-ÒÎflÔÓ ÍÓÌÚÓÎË‡ÌÓ ÔÓÛ˜‚‡ÌÂ, ‚ ÍÓÂÚÓ Â Ò‡‚Ìfl‚‡Ì ÂÙÂÍÚ‡ ̇ piracetam (6 „/‰ÂÌ) Ò˙Ò ÂÙÂÍÚ‡ ̇ Citicoline (750 „/‰ÂÌ) ÔË „ÛÔ‡ ÓÚ 40 Ô‡ˆËÂÌÚË Ò Ú‡‚χ ̇ „·‚‡Ú‡. ìÒÚ‡ÌÓ‚ÂÌ Â ·Î‡„ÓÔËflÚÂÌ ËÁıÓ‰ ÔË 75% ÓÚ Ô‡ˆËÂÌÚËÚ ÎÂÍÛ‚‡ÌË Ò Citicoline, ‚ Ò‡‚ÌÂÌËÂ Ò 33% ÔË „ÛÔ‡Ú‡, ÎÂÍÛ‚‡Ì‡ Ò piracetam. Carcassonne and LeTourneau 1979 (13), Ò‡ ÔÓ‚ÂÎË ‰‚ÓÈÌÓ-ÒÎflÔÓ ÍÓÌÚÓÎË‡ÌÓ ÔÓÛ˜‚‡Ì ÔË 43 ‰Âˆ‡ ̇ ‚˙Á‡ÒÚ ÏÂÊ‰Û 5 Ë 15 „Ó‰ËÌË (75% ÏÓϘÂÚ‡) Ò Ì‡Û¯ÂÌËfl ̇ Ò˙Á̇ÌËÂÚÓ ÒΉ óåí. Ä‚ÚÓËÚ ÛÒÚ‡ÌÓ‚fl‚‡Ú ÔË Ú‡ÁË ‚˙Á‡ÒÚÓ‚‡ „ÛÔ‡, ˜Â Citicoline Á̇˜ËÚÂÎÌÓ ÛÒÍÓfl‚‡ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ì‡ Ò˙Á̇ÌËÂÚÓ Í˙Ï ÌÓχÎÌÓ Ò˙ÒÚÓfl-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

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ÌËÂ, ÛÒÍÓfl‚‡ ËÁ˜ÂÁ‚‡ÌÂÚÓ Ì‡ ÌÂ‚ÌÓÔÒËıÓÚ˘ÌÓÚÓ ‡ÁÒÚÓÈÒÚ‚Ó Ë ÔÓÏÂÌËÚ ‚ ÏÓÁ˙˜Ì‡Ú‡ ÂÎÂÍÚÓ„ÂÌÂÁ‡. ëàÉìêçéëí à èéçéëàåéëí çÄ CITICOLINE. Ç˙‚ ‚Ò˘ÍË ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl Ò ÔÓ‰˜ÂÚ‡‚‡ ‰Ó·‡Ú‡ ÔÓÌÓÒËÏÓÒÚ Ë ÒË„ÛÌËfl ÔÓÙËΠ̇ Citicoline, ͇ÍÚÓ Ë ÓÚÒ˙ÒÚ‚ËÂÚÓ Ì‡ ÒÂËÓÁÌË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË. äÎËÌ˘ÌÓ ÔÓÛ˜‚‡ÌÂ Ò Ó‡ÎÌÓ ÔË·„‡Ì Citicoline (600 Ï„/ ‰ÂÌ) ‚ ÔÓ‰˙ÎÊÂÌË ̇ 16 ‰ÌË ÔË 2817 Ô‡ˆËÂÌÚË, ÒÚ‡‰‡˘Ë ÓÚ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚Ë Á‡·ÓÎfl‚‡ÌËfl, ‰ÂÏÂ̈Ëfl Ë ‰. ÛÒÚ‡ÌÓ‚fl‚‡ ÒË„ÛÌÓÒÚ Ë ·ÂÁÓÔ‡ÒÚÌÓÒÚ Ì‡ ωË͇ÏÂÌÚ‡ (28). ëÚ‡Ì˘ÌË ÂÙÂÍÚË Ò‡ ̇·Î˛‰‡‚‡ÌË Ò‡ÏÓ ÔË 5.01% ÓÚ Ô‡ˆËÂÌÚËÚÂ. ë‰ Úflı ̇È-˜ÂÒÚÓ Ò‡ „ËÒÚË‡ÌË ı‡ÌÓÒÏË·ÚÂÎÌË ÔÓ·ÎÂÏË ‚ 3,6% ÓÚ ÒÎÛ˜‡ËÚÂ. ç ҇ ÛÒÚ‡ÌÓ‚ÂÌË ÔÓÏÂÌË ‚ ·ËÓıËÏ˘ÌËÚ ÔÓ͇Á‡ÚÂÎË Ì‡ Í˙‚Ú‡. Dinsdale et al. (21) Ò‡ ÔÓ‚ÂÎË ÍÎËÌ˘ÌÓ ÔÓÛ˜‚‡Ì Á‡ ÔÓÌÓÒËÏÓÒÚÚ‡ Ë ·ÂÁÓÔ‡ÒÚÌÓÒÚÚ‡ ̇ Citicoline ÔË 12 ‰Ó·Ó‚ÓÎˆË Ò Ó‡ÎÌÓ ÔËÎÓÊÂÌË ̇ ωË͇ÏÂÌÚ‡ (600 Ï„/ ‰ÂÌ Ë 1000/ ‰ÂÌ) ‚ ÔÓ‰˙ÎÊÂÌË ̇ 5 ÔÓÒΉӂ‡ÚÂÎÌË ‰ÌË. èÓÎÛ˜ÂÌËÚ ÂÁÛÎÚ‡ÚË Ò‡ Ò‡‚ÌÂÌË Ò ÚÂÁË ÓÚ „ÛÔ‡Ú‡ ̇ placebo. ìÒÚ‡ÌÓ‚ÂÌË Ò‡ Í‡ÚÍÓÚ‡ÈÌË „·‚Ó·ÓÎËfl ÔË 4 Ô‡ˆËÂÌÚË Ì‡ ÌËÒ͇ڇ ‰ÓÁ‡ Ë ÔË 5 Ô‡ˆËÂÌÚË Ì‡ ‚ËÒÓ͇ڇ ‰ÓÁ‡ Ë Ò‡ÏÓ ÔË Â‰ËÌ Ô‡ˆËÂÌÚ ‚ „ÛÔ‡Ú‡ ̇ placebo. ç ҇ ÛÒÚ‡ÌÓ‚ÂÌË ÔÓÏÂÌË ‚ ıÂχÚÓÎӄ˘ÌËÚÂ Ë ·ËÓıËÏ˘ÌËÚ ËÁÒΉ‚‡ÌËfl, ͇ÍÚÓ ÔË ÖäÉ Ë EEG ËÁÒΉ‚‡ÌËflÚ‡. ê„ËÒÚË‡Ì‡  ÓÚ΢̇ ÔÓÌÓÒËÏÓÒÚ Í˙Ï Citicoline ÓÚ ‚Ò˘ÍË Û˜‡ÒÚÌËˆË ‚ ÍÎËÌ˘ÌÓÚÓ ÔÓÛ˜‚‡ÌÂ.

îË„. 3. EÙÂÍÚ Ì‡ Citicoline ‚˙ıÛ ÓÒ‚Ó·Óʉ‡‚‡ÌÂÚÓ Ì‡ ‡‡ıˉÓÌÓ‚‡ ÍËÒÂÎË̇ ‚ ÏÓÁ˙͇ ̇ ÔÎ˙ıÓ‚Â ÒΉ Í‡ÚÍÓ‚ÂÏÂÌ̇ ËÒıÂÏËfl.

áÄäãûóÖçàÖ PÂÁÛÎÚ‡ÚËÚ ÓÚ ÏÌÓ„Ó·ÓÈÌËÚ ÏÛÎÚˈÂÌÚÓ‚Ë ‰‚ÓÈÌÓ ÒÎÂÔË ‡Ì‰ÓÏËÁË‡ÌË Ë Ô·ˆÂ·ÓÍÓÌÚÓÎË‡ÌË ÍÎËÌ˘ÌË ÔÓÛ˜‚‡ÌËfl ÔË ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ Ë ˜ÂÂÔÌÓ-ÏÓÁ˙˜Ì‡ Ú‡‚χ ÔÓ͇Á‚‡Ú, ˜Â citicoline ÛÒÍÓfl‚‡ îË„. 4. éˆÂÌ͇ ̇ Ò˙ÒÚÓflÌËÂÚÓ Ì‡ ·ÓÎÌËÚÂ Ò ËÒıÂÏ˘ÌË ÏÓÁ˙˜ÌË ËÌÒÛÎÚË Ì‡ 14-fl ‰ÂÌ ÒΉ ÔËÎÓÊÂÌË ̇ Citicoline Ë placebo.

îË„.1. äËÌÂÚË͇ ̇ Na+/K+ - ÄíPase ‡ÍÚË‚ÌÓÒÚ Ë ÍÓ΢ÂÒÚ‚ÓÚÓ ‚Ó‰‡ ÔË ÏÓÁ˙˜ÂÌ ÓÚÓÍ ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ ÔÂËÓ‰‡ ‚ ˜‡ÒÓ‚Â.

îË„. 5. è˙ÎÌÓ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ì‚ÓÎӄ˘̇ڇ ÒËÏÔÚÓχÚË͇ ÒÔÓ‰ Ò͇ÎËÚ Á‡ ÓˆÂÌ͇: Rankin, NIH Ë Barthel

îË„. 2. ÖÙÂÍÚ Ì‡ Citicoline ‚ ÌËÒ͇ ‰ÓÁ‡ (100 mg/kg) Ë ‚ËÒÓ͇ ‰ÓÁ‡ (500 mg/kg) ‚˙ıÛ ËÌÙ‡ÍÚÌËfl Ó·ÂÏ.

‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ, ÔÓ‚ÎËfl‚‡ ÍÓ΢ÂÒÚ‚ÂÌËÚ ̇Û¯ÂÌËfl ̇ Ò˙Á̇ÌËÂÚÓ, ÔÓ‰Ó·fl‚‡ Í‡ÈÌËfl ÙÛÌ͈ËÓ̇ÎÂÌ ÂÁÛÎÚ‡Ú, ÒÍ˙Òfl‚‡ ÔÂËÓ‰‡ ̇ ·ÓÎÌ˘ÌËfl ÔÂÒÚÓÈ. ë ÔËÎÓÊÂÌËÂÚÓ Ì‡ ωË͇ÏÂÌÚ‡ Ò ÛÒÍÓfl‚‡ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ ÔË ÏÓÚÓÂÌ ‰ÂÙˈËÚ Ë Ò Ò˙Á‰‡‚‡ ÛÒÚÓȘ˂‡ ÚẨÂ̈Ëfl Á‡ ÔÓ‰Ó·ÂÌË ̇ ÏÓÚÓÌËÚÂ Ë ÍÓ„ÌËÚË‚ÌË ‡ÁÒÚÓÈÒÚ‚‡. Citicoline  ‰Ó· ÔÓÌÓÒËÏ Ï‰Ë͇ÏÂÌÚ ·ÂÁ ÒÂËÓÁÌË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË.


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8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

îË„. 6. P‰Û͈Ëfl ̇ ËÌÙ‡ÍÚÌËfl Ó·ÂÏ ÒΉ 6 Ò‰Ï˘ÌÓ Î˜ÂÌË Ò˙Ò Citicoline.

18. 19. 20. 21. 22. 23. 24. 25. 26.

îË„. 7. ÖÙÂÍÚ Ì‡ Citicoline ÔË Î˜ÂÌËÂÚÓ Ì‡ óåí (<0.01 ‰ÂÌ 60)

27. 28. 29. 30. 31. 32. 33. 34. 35. 36.

îË„. 8. Ö‚ÓβˆËfl ̇ ÏÓÁ˙˜ÌËfl ÓÚÓÍ ÔË äí ËÁÒΉ‚‡Ì ÒΉ 14-‰Ì‚ÌÓ Î˜ÂÌË Ò˙Ò Citicoline ãàíÖêÄíìêÄ 1. 2. 3. 4. 5. 6. 7.

Adibhatla, R. M., Hatcher, J. F., Dempsey, R. J. Phospholipase A2, hydroxyl radicals and lipid peroxidation in transient cerebral ischemia. Antioxid. Redox Signal, 2003, 5, 647–654. Adibhatla, R. M., Hatcher, J. F., Dempsey, R.J. Citicoline: Neuroprotective mechanisms in cerebral ischemia. J. Neurochem, 2002, 80, 12–23. Adibhatla, R. M., Hatcher, J. F., Tureyen, K, Tsao, F., Dempsey, R.J. Does CDP-choline partly counteract TNF-a Mediated events after stroke? Soc. Neurosci, 2004, 455.10. Adibhatla, R. M., Hatcher, J. F. Citicoline decreases phospholipase A2 stimulation and hydroxylradical generation in transient cerebral ischemia. J. Neurosci. Res., 2003, 73, 308–315. Agut, J. et al. CDP-choline and striatum extracellular glutamate levels. Submitted, 2000. Agut, J. et al. Effects of orally administered cytidine 5'?diphosphate choline on brain phospholipid content. Ann N Y Acad Sci, 1993, 695, 318-320. Agut. J. et al. Oral CDP-choline administration to rats increases glutamate and decreases GABA cortical brain levels. 27th Annual Meeting of the Society of Neuroscience. New Orleans, Louisiana, USA, 1997.

37. 38. 39. 40. 41. 42.

43.

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Alexandrov, A.V. Citicoline: FerrerInternacional. Curr. Opin. Invest. Drugs, 2001, 2, 1757–1762. Arrigoni, E. et al. Effects of CDP?choline on phospholipase A2 and cholinephosphotransferase activities following a cryogenic brain injury in the rabbit. Biochem Pharmacol, 36, 1987, 21, 3697?3700. Babb, S.M. et al. Differential effect of CDP?choline on brain cytosolic choline levels in younger and older subjects as measured by proton magnetic resonance spectroscopy. Psychopharmacology, 1996, 127, 88?94. Baskaya, M.K. et al. Neuroprotective effects of citicoline on brain edema and blood-brain barrier breakdown after traumatic brain injury. J Neurosurg, 2000, 92, 448-452. Calatayud Maldonado, V.,Calatayud Perez, J.B., Aso Escario. Effects of CDP-choline on the recovery of patients with head Injury. J. Neurol. Sci., 1991, 103, 15-18. Carcassonne, M., Le Tourneau, J.N. Etude double insu du Rexort en neurotraumatologue infantile. La Vie Medicale, 1979, 12, 1007. Cervos Navarro, J., Lafuente, J.V. Effect of cytidine diphosphate choline on ultraviolet-induced brain edema. Adv Neurol, 1990, 52, 421?429. Clark, W.M. et al. A randomized efficacy trial of citicoline in patients with acute ischemic stroke. Stroke, 1999, 30, 2592-2597. Clark, W.M. et al., for the Citicoline Stroke Study Group. A randomized dose-response trial of citicoline in acute ischemic stroke patients. Neurology, 1997, 49, 671-678. Cui, Z. and Houweling, M. Phosphatidyl-choline and cell death. Biochim. Biophys. Acta, 2000, 1585, 87–96. Davalos, A., Castillo, J., Alvarez - Sabin, J., et al. Oral citicoline in acute ischemic stroke: An individual patient data pooling analysis of clinical trials. Stroke, 2002, 33, 2850 – 2857. De Blas, A., Martinez Cubells, J., Hernando, C. Valoracion de la efectividad de la citicolina en el tratamiento de los traumatismos craneoencefalicos.. Med. Clin. (Barc.), 1986, 84, 41 – 44. De la Herran, J., Cortina, C., Salazar, J., Fernandes, F. Utilizacion del citidindifosfato de colina en las lesiones encefalicas graves. Actas luso-espanolas de neurologia, psiquiatria y ciencias afines, 1978, 6, 3-12. Dinsdale, J.R., Griffits, G.K., Castello, J., et al. CDP-choline: Repeated oral dose tolerance studies in adult healthy volunteers. Arzneimittelforschung, 33, 1983, 2, 1061-1065. Dixon, C.E. et al. Effects of CDP?choline treatment on neurobehavioral deficits after TBI and hippocampal and neocortical acetylcholine release. J Neurotrauma, 1997, 14, 161-169. Espagno, M., Trenoulet, M., Gigaud Espagno, C. Study about CDP-choline action on post-trauma vigilance troubles. La Vie Medicale, 1979, 3, 195 – 196. Exton, J. H. Phosphatidyl-choline breakdown and signal trans-duction. Biochim. Biophys. Acta, 1994, 1212, 26–42. Gammans, R.E., Sherman, D.G. ECCO 2000 Study of citicoline for treatment of acute ischemic stroke: Final results. 25th International Stroke Conference, New Orleans, Louisiana (USA), 2000. Kakihana, M. et al. Effects of CDP-choline on neurologic deficits and cerebral glucose metabolism in a rat model of cereberal ischemia. Stroke, 1988, 19, 217-222. Katsuki, H., Okuda, S. Arachidonic acid as a neurotoxic and neurotrophic substance. Prog. Neurobiol., 1995, 46, 607–636. Klein, J. Membrane breakdown in acute and chronic neurodegeneration: Focus on choline-containing phospholipids. J. Neur. Transm., 2000, 107, 1027–1063. Klein, J., Chalifa, V., Liscovitch, M., Lo?elholz, K. Role of phospholipase D activation in nervous system physiology and path of physiology. J. Neurochem., 1995, 65, 1445–1455. Kontos, H. A. Oxygen radicals in cerebral ischemia. Stroke, 2001, 32, 2712 – 2716. Lecuire, J. Duplay, J. Sperimentazione in doppio cieco della citicolina versus meclofenossato in pazienti colpiti da trauma cranico. Giornale Italiano di Recherche Clinique et Terapeutiche, 1982, 3, 51 – 55. Lecuire, J. Neurosurgery Department. Hptital de Lyon. “Cranial trauma: comparative trial piracetam – CDP – Choline”. Ther. Pharmacal. Clin., 3, 1985, 30, 3 – 7. Leon-Carrion, J., Dominguez-Roldan, J. M., Murillo-Cabeszas, F., et al. The role of citicoline in neuropsychological training after traumatic brain injury. NeuroRehabilitation, 2000, 14, 33-40. Levin, H.S.. Treatment of postconcussional symptoms with CDP-choline. J. Neurol. Scien., 1991,103, 39 – 42. Li, Y.H., Maher, P., Schubert, D. Phosphatidylcholine speci?c phospholipase C regulates glutamate-induced nerve cell death. Proc. Natl. Acad. Sci. USA, 1998, 95, 7748–7753. Lopez Coviella, I. et al. Evidence that 5'?cytidinediphosphocholine can affect brain phospholipid composition by increasing choline and cytidine plasma levels. J Neurochem, 1995, 65, 889?894. Lozano, R. CDP-choline in the treatment of cranio-encephalic trauma. J. Neurol Sci, 1991, 103, 43-47. Martinet, M. et al. Effects of Cytidine?5' diphosphocholine on norepinephrine, dopamine and serotonin synthesis in various regions of the rat brain. Arch Int Pharmacodyn, 1979, 239, 52?61. Mattson, M. P., Culmsee, C., Yu, Z. F. Apoptotic and antiapoptotic mechanisms in stroke. Cell Tissue Res, 2000, 301, 173–187. McCracken, E., Graham, D.I., Nilsen, M., Stewart, J., Nicoll, J.A., Horsburgh, K. 4 – Hydroxynonenal immunoreactivity is increased in human hippocampus after global ischemia. Brain Pathol., 2001, 11, 414–421. Moriyama, M., Tsukumo, T., Nagakawa, Y. Effect of CDP-choline on head injury. Gendai no Rinsho, 1967, 1, 114-120. Murphy, E.J., Horrocks, L.A. Mechanisms of action of CDPcholine and CCPethanolamine on fatty acid release during ischemia of brain. En Bazan NG (ed): Lipid mediators in ischemic brain damage and experimental epilepsy. New trends lipid mediators res. Basel, Karger, 1990, 4, 67-84. égashiwa, M., Sano, K., Manaka, S., et al. Effectiveness of CDP-choline on disturbance of consciousness (DOC): An experimental study of concussive head injury in mice. 2. A controlled trial in patients with DOS. En: Zappia, V., Kennedy, E.P., Nilsson, B.I., Galleti, P. (Eds.). Novel Biohemical, Pharmacological and Clinical Aspects of Cytidinediphosphocholine. Elsevier Science Publishing Co. Inc., Amsterdam, 1985, 299-304.


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‡ÔËÎ, 2007

44. Raggueneau, J.L., Jarrige, B. National inquire on the outcome of severe head injuries: Analysis of 921 injured patients treated with CDP-choline. Agressologie, 1988, 29, 439-443. 45. Rao, A. M., Hatcher, J. F., Dempsey, R. J. Lipid metabolism in ischemic neuronal death. Recent Res. Develop. Neurochem., 1999, 2, 533–549. 46. Richerr, E., Cohadon, F. Essai therapeutique d’un precurseur del phospholipids sur le traitement des comas traumatiques graves. Symposium International: Souffrance Cerebrale et Precurseurs del Phospholipides, Paris, 1980. 47. Rigoulet, M. et al. Unilateral brain injury in the rabbit: Reversible and irreversible damage of the membranal ATPases. J Neurochem, 1979, 32, 535?541. 48. Secades, J.J. CDP-choline: Update and review of its pharmacology and clinical use. Methods Find. Exp. Clin. Pharmacol, 2002, 24, 1 –53. 49. Six, D. A., Dennis, E. A. The expanding super-family of phospholipaseA2 enzymes: Classi?cation and characterization. Biochim. Biophys. Acta, 2000, 1488, 1–19. 50. Stoll et al. Choline ingestion increases the resonance of choline?containing compounds in human brain: An in vivo proton magnetic resonance study. Biol Psychiat, 1995, 37, 170?174. 51. Tazaki, Y., Sakai, K., Otomo, E., et al. Treatment of acute cerebral infarction with a choline precusor in a multicenter double-blind controlled study. Stroke, 1988, 19, 211-216. 52. Ter Horst, G. J., Korf, J. (eds.). Clinical pharmacology of cerebral ischemia.

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N J: Humana. 53. Tronchere, H., Record, M., Terce, F., Chap, H. Phosphatidyl-choline cycle and regulation of phosphatidylcholine biosynthesis by enzyme translocation. Biochim. Biophys. Acta, 1994, 1212, 137–151. 54. Trovarelli, G. et al. Effect of cytidine diphosphate choline (CDP?choline) on ischemia induced alterations of brain lipid in the gerbil. Neurochem Res, 1981, 6, 821?833. 55. Uchida, K. Current status of acrole in as a lipid peroxidation product. Trends Cardiovasc. Med, 1999, 9, 109–113. 56. Warach, S. Dose dependent reduction in infarct growth with citicoline treatment: evidence of neuro protection in human stroke? Stroke, 2002, 33, 354. 57. Warach, S. et al. Reduction of lesion volume in human stroke by citicoline detected by diffusion weighted magnetic resonance imaging: A pilot study. Ann Neurol, 1996, 40, 527-528. ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl:

èÓÙ. è. ëÚ‡ÏÂÌÓ‚‡ ìåÅÄã ◊ñ‡ˈ‡ âÓ‡Ì̇”, ÍÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl ìÎ. ÅflÎÓ ÏÓ 8 ëÓÙËfl, 1527 íÂÎ: 02 94 32 214

é·ÁÓ ëäêàçàçÉéÇà çÖÇêéèëàïéãéÉàóçà íÖëíéÇÖ áÄ äéÉçàíàÇçà çÄêìòÖçàü à ÑÖåÖçñàü 1

à. ÑËÏËÚÓ‚1, ç. ÑÂ΂‡1, ã. í‡ÈÍÓ‚2 è˙‚‡ ÍÎËÌË͇ ÔÓ ÌÂ‚ÌË ·ÓÎÂÒÚË, ìåÅÄã ◊ë‚ÂÚ‡ å‡Ë̇” – LJ̇ 2ç‚ÓÎӄ˘̇ ÍÎËÌË͇, ìåÅÄã ◊ÄÎÂÍ҇̉Ó‚Ò͇” – ëÓÙËfl

SUMMARY NEUROPSYCHOLOGICAL SCREENING TESTS FOR COGNITIVE IMPAIRMENT AND DEMENTIA I. Dimitrov, N. Deleva, L. Traykov The emphasis in dementia diagnostics is nowadays put on uncovering early cognitive impairment, which appears before the development of the classical clinical picture. In this regard, quick and accurate screening methods are sought, among which neuropsychological tests are of primary importance. Though some instruments possess undisputed advantages, they should not be used as single diagnostic tools. Their best use would be to direct the appropriate patients to dementia specialists, with a view to a detailed neuropsychological and clinical assessment. KEY WORDS: cognitive impairment, dementia, neuropsychological tests, screening. êÖáûåÖ Ä͈ÂÌÚ˙Ú ‚ ‰Ë‡„ÌÓÒÚË͇ڇ ̇ ‰ÂÏÂ̈ËËÚ ‚Ò ÔÓ˜ÂÒÚÓ Ò ÔÓÒÚ‡‚fl ‚˙ıÛ ÛÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ì‡ ̇˜‡ÎÌË ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl, ÔÓfl‚fl‚‡˘Ë Ò Ӣ ÔÂ‰Ë ‡Á‚ËÚËÂÚÓ Ì‡ Í·Ò˘ÂÒ͇ڇ ÍÎËÌ˘̇ ͇ÚË̇ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ. Ç˙‚ ‚˙Á͇ Ò ÚÓ‚‡ Ò Ú˙ÒflÚ ·˙ÁË Ë ÚÓ˜ÌË ÏÂÚÓ‰Ë Á‡ ÒÍËÌËÌ„, Ò‰ ÍÓËÚÓ Ô˙‚ÓÒÚÂÔÂÌÌÓ Á̇˜ÂÌË ËÏ‡Ú Ì‚ÓÔÒËıÓÎӄ˘ÌËÚ ÚÂÒÚÓ‚Â. Ç˙ÔÂÍË ˜Â ÌflÍÓË ÓÚ Úflı ËÏ‡Ú ÌÂÓÒÔÓËÏË Í‡˜ÂÒÚ‚‡, Ì ·Ë ÒΉ‚‡ÎÓ Ú ‰‡ Ò ËÁÔÓÎÁ‚‡Ú Ò‡ÏÓÒÚÓflÚÂÎÌÓ Á‡ ÔÓÒÚ‡‚flÌ ̇ ‰Ë‡„ÌÓÁ‡, ‡ Á‡ ̇ÒÓ˜‚‡Ì ̇ ÔÓ‰ıÓ‰fl˘Ëfl ÍÓÌÚËÌ„ÂÌÚ Í˙Ï ÒÔˆˇÎËÒÚË ‚ ӷ·ÒÚÚ‡ ̇ ‰ÂÏÂ̈ËËÚÂ, Ò Ó„Î‰ ÔÓ‰Ó·ÌÓ Ì‚ÓÔÒËıÓÎӄ˘ÌÓ Ë ÍÎËÌ˘ÌÓ ËÁÒΉ‚‡ÌÂ. äãûóéÇà Ñìåà: ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl, ‰ÂÏÂ̈Ëfl, Ì‚ÓÔÒËıÓÎӄ˘ÌË ÚÂÒÚÓ‚Â, ÒÍËÌËÌ„. èÓÒÚ‡‚flÌÂÚÓ Ì‡ ‰Ë‡„ÌÓÁ‡ ‰ÂÏÂ̈Ëfl  ÒÎÓÊÂÌ ÔÓˆÂÒ, ‚Íβ˜‚‡˘ ÔÓ‰ˈ‡ ÓÚ Ì‚ÓÔÒËıÓÎӄ˘ÌË, ÍÎËÌ˘ÌË, Ó·‡ÁÌË Ë Î‡·Ó‡ÚÓÌË ËÁÒΉ‚‡ÌËfl. çflÍÓË ÓÚ Úflı ˆÂÎflÚ Ó·ÂÍÚË‚ËÁË‡Ì ̇ ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl, ‡ ‰Û„Ë ÒÂ

ÔÓ‚Âʉ‡Ú Ò Ó„Î‰ Ú˙ÒÂÌ ËÎË ËÁÍβ˜‚‡Ì ̇ ‚˙ÁÏÓÊÌË Ó„‡Ì˘ÌË ÂÚËÓÎӄ˘ÌË Ù‡ÍÚÓË. è‡‚ËÎÌÓÚÓ Ë Ì‡‚ÂÏÂÌÌÓ ‰Ë‡„ÌÓÒÚˈË‡Ì ̇ ‰ÂÏÂ̈ËflÚ‡, ̇ ÌÂÈÌËfl ÚËÔ Ë Ô˘Ë̇ڇ Á‡ ‡Á‚ËÚËÂÚÓ È, ·Ë ÏÓ„ÎÓ ‰‡ ÔÓ‚ÎËfl ‚ Á̇˜ËÚÂÎ̇ ÒÚÂÔÂÌ Î˜ÂÌËÂÚÓ Ë ÔÓ„ÌÓÁ‡Ú‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ. Ä͈ÂÌÚ˙Ú ‚ ‰Ë‡„ÌÓÒÚË͇ڇ ̇ ‰ÂÏÂ̈ËËÚ ‚Ò ÔÓ˜ÂÒÚÓ Ò ÔÓÒÚ‡‚fl ‚˙ıÛ ÛÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ì‡ ̇˜‡ÎÌË ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl, ÔÓfl‚fl‚‡˘Ë Ò Ӣ ÔÂ‰Ë ‡Á‚ËÚËÂÚÓ Ì‡ Í·Ò˘ÂÒ͇ڇ ÍÎËÌ˘̇ ͇ÚË̇ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ. á̇˜ÂÌËÂÚÓ Ì‡ ‡Ì̇ڇ ‰Ë‡„ÌÓÁ‡ Ò ÔÓ‰˜ÂÚ‡‚‡ ÓÚ Ò˙Ó·˘‡‚‡ÌËÚ ÔÓ-‰Ó·Ë ÂÁÛÎÚ‡ÚË ÔË Á‡ÔÓ˜‚‡Ì ̇ ΘÂÌË ‚ ‡ÌÌËfl ÒÚ‡‰ËÈ, ‚Íβ˜ËÚÂÎÌÓ ÔË Ì‡È-˜ÂÒÚÓ Ò¢‡ÌËfl ÚËÔ ‰ÂÏÂ̈Ëfl – ·ÓÎÂÒÚÚ‡ ̇ ÄΈı‡ÈÏÂ (ÅÄ). ëÎÓÊÌÓÒÚÚ‡ ̇ ‰Ë‡„ÌÓÒÚ˘ÌËfl ÔÓˆÂÒ, ͇ÍÚÓ Ë ÌÂÓ·ıÓ‰ËÏÓÒÚÚ‡ ‰‡ ·˙‰Â ‚Ó‰ÂÌ ÓÚ Í‚‡ÎËÙˈË‡ÌË ÒÔˆˇÎËÒÚË, Á‡ÚÛ‰Ìfl‚‡Ú ÔÓ‚Âʉ‡ÌÂÚÓ ÏÛ ‚ Ô‡ÍÚË͇ڇ ËÁ‚˙Ì ÒÔˆˇÎËÁË‡ÌË Á‚Â̇. íÓ‚‡  ̇ÎÓÊËÎÓ ‚ ÔÓÒΉÌËÚ ‰ÂÒÂÚËÎÂÚËfl ‰‡ Ò Ú˙ÒflÚ Ë Ò˙Á‰‡‚‡Ú Í‡ÚÍË ÒÍËÌËÌ„Ó‚Ë ËÌÒÚÛÏÂÌÚË, ÍÓËÚÓ ‰‡ ÔÓ‰ÔÓχ„‡Ú ÓÚÍË‚‡ÌÂÚÓ Ì‡ ÒÎÛ˜‡Ë Ò ‰ÂÏÂ̈Ëfl Ë ‰‡ ÏÓ„‡Ú ‰‡ Ò ÔË·„‡Ú χÒÓ‚Ó, ‚ Ú.˜. Ë ÓÚ ÌÂÒÔˆˇÎËÒÚË ‚ ӷ·ÒÚÚ‡ ̇ ÍÓ„ÌËÚË‚ÌËÚ ̇Û¯ÂÌËfl. éÒÓ·ÂÌÓ ‚‡ÊÌÓ Â Ì‡Î˘ËÂÚÓ Ì‡ ÚÂÒÚÓ‚Â, ÔÓ‰ıÓ‰fl˘Ë Á‡ Ó·˘‡Ú‡ Ô‡ÍÚË͇, Í˙‰ÂÚÓ ·ÓflÚ Ì‡ Ô‡ˆËÂÌÚËÚ Ò˙Ò ÒÛ·ÂÍÚË‚ÌË ÓÔ·͂‡ÌËfl ÓÚ Ì‡Û¯ÂÌËfl ̇ Ô‡ÏÂÚÚ‡  Á̇˜ËÚÂÎÂÌ. ◊à‰Â‡ÎÌËflÚ” ÒÍËÌËÌ„Ó‚ ÚÂÒÚ ·Ë ÒΉ‚‡ÎÓ ‰‡ ÓÚÍË ‚Ò˘ÍË ÒÎÛ˜‡Ë Ò ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl Ò‰ ËÁÒΉ‚‡ÌËfl ÍÓÌÚËÌ„ÂÌÚ (˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ 100%), ͇ÚÓ ‚ Ò˙˘ÓÚÓ ‚ÂÏ Í·ÒËÙˈË‡ ‚Ò˘ÍË ËÌ‰Ë‚Ë‰Ë ·ÂÁ ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl ͇ÚÓ Á‰‡‚Ë (ÒÔˆËÙ˘ÌÓÒÚ 100%). Ç˙ÔÂÍË ˜Â Ò‡ ‡Á‡·ÓÚÂÌË ÏÌÓÊÂÒÚ‚Ó ÚÂÒÚÓ‚Â, ‚Ò Ӣ Ì  Ò˙Á‰‡‰ÂÌ Ú‡Í˙‚, ÍÓÈÚÓ ‰‡  ‰ÌÓ‚ÂÏÂÌÌÓ Í‡Ú˙Í, Ò Ï‡ÍÒËχÎ̇ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ Ë ÒÔˆËÙ˘ÌÓÒÚ Ë Ì‚ÎËfl¢ Ò ÓÚ ÒÚ‡Ì˘ÌË Ù‡ÍÚÓË. íÓ‚‡  ‰̇ ÓÚ ‚Ӊ¢ËÚ Ô˘ËÌË ‰‡ Ì Ò ÔÂÔÓ˙˜‚‡ ÔÓ‚Âʉ‡ÌÂÚÓ Ì‡ χÒÓ‚ ÒÍËÌËÌ„ ̇ ˆfl·ڇ ÔÓÔÛ·ˆËfl ̇‰ ÓÔ‰ÂÎÂ̇ ‚˙Á‡ÒÚ, Í˙‰ÂÚÓ Ò Ә‡Í‚‡ ÔÓ-‚ËÒÓÍ ÓÚÌÓÒËÚÂÎÂÌ ‰flΠ̇ Îˈ‡Ú‡ Ò ÍÓ„ÌËÚË‚-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÌË Ì‡Û¯ÂÌËfl Ë ‰ÂÏÂ̈Ëfl. ᇠÔÓ-ÛÏÂÒÚÌÓ Ò ҘËÚ‡ ̇ ÒÍËÌËÌ„ ‰‡ ·˙‰‡Ú ÔÓ‰ÎÓÊÂÌË Ò‡ÏÓ ÚÂÁË, ÍÓËÚÓ ËÏ‡Ú Ò˙ÓÚ‚ÂÚÌË ÓÔ·͂‡ÌËfl, ËÎË ˜ËËÚÓ ·ÎËÁÍË ËÎË ÎÂÍÛ‚‡˘Ë ÎÂ͇Ë Ò‡ Á‡·ÂÎflÁ‡ÎË ÔÓÏfl̇ ‚ ӷ˘‡ÈÌÓÚÓ ËÏ ÌË‚Ó Ì‡ ÙÛÌ͈ËÓÌË‡ÌÂ. ç‚ÓÔÒËıÓÎӄ˘ÌËÚ ÚÂÒÚÓ‚Â Ô‰ÓÒÚ‡‚flÚ ‚˙ÁÏÓÊÌÓÒÚÚ‡ Á‡ ÔÓÎÛ˜‡‚‡Ì ̇ ˆËÙÓ‚‡ ÓˆÂÌ͇ ̇ ËÁÒΉ‚‡ÌËÚ ˜ÂÁ Úflı ÍÓ„ÌËÚË‚ÌË ÙÛÌ͈ËË. äÓ„‡ÚÓ Ò ËÁÔÓÎÁ‚‡Ú Á‡ ÒÍËÌËÌ„, ·Ë ÒΉ‚‡ÎÓ ‰‡ Ò ÔÓ‰·Â Ô‡„Ó‚‡ ÒÚÓÈÌÓÒÚ, ‡Á‰ÂÎfl˘‡ ÔÓÎÓÊËÚÂÎÌÓ ÓÚ ÓÚˈ‡ÚÂÎÌÓ ÒÍËÌË‡ÌËÚÂ. ᇠÔӂ˜ÂÚÓ ÚÂÒÚÓ‚Â Ò‡ Ô‰ÎÓÊÂÌË ÔÓ‰Ó·ÌË ÒÚÓÈÌÓÒÚË, ÍÓËÚÓ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÔÓÏÂÌflÌË ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ ˆÂÎËÚ ̇ ËÁÒΉ‚‡ÌÂÚÓ. ç‡È-˜ÂÒÚÓ ÔË ÒÍËÌËÌ„ Ò ÔÓ‰·Ë‡Ú Ô‡„Ó‚Ë ÒÚÓÈÌÓÒÚË, ÔË ÍÓËÚÓ ‰‡‰ÂÌËflÚ ÚÂÒÚ ÔÓ͇Á‚‡ ‚ËÒÓ͇ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ, ‰ÓË ÚÓ‚‡ ‰‡  Á‡ ÒÏÂÚ͇ ̇ ËÁ‚ÂÒÚÌÓ ÔÓÌËʇ‚‡Ì ̇ ÒÔˆËÙ˘ÌÓÒÚÚ‡. Ç Ô‡ÍÚË͇ڇ Ò ËÁÔÓÎÁ‚‡Ú ‡Á΢ÌË ÒÍËÌËÌ„Ó‚Ë ÚÂÒÚÓ‚Â, ͇ÚÓ ÌflÍÓË ÓÚ Úflı Ò‡ ¯ËÓÍÓ ‡ÁÔÓÒÚ‡ÌÂÌË Ë ÛÚ‚˙‰ÂÌË. èÓÌflÍÓ„‡, Ò Ó„Î‰ Ò˙˜ÂÚ‡‚‡Ì ̇ Ô‰ËÏÒÚ‚‡Ú‡ Ë ÍÓÏÔÂÌÒË‡Ì Ì‰ÓÒÚ‡Ú˙ˆËÚ ̇ ‰‚‡ ËÎË Ôӂ˜ ËÌÒÚÛÏÂÌÚ‡, e ÛÏÂÒÚÌÓ Ú ‰‡ Ò ÍÓÏ·ËÌË‡Ú ‚ ·‡ÚÂËfl. Ç Ì‡ÒÚÓfl˘‡Ú‡ ÒÚ‡ÚËfl Ò‡ ‡Á„Ή‡ÌË ÌflÍÓË ÓÚ ÚÂÒÚÓ‚ÂÚÂ, ÔÂÔÓ˙˜‚‡ÌË Á‡ ËÁÔÓÎÁ‚‡Ì ÔË ÒÍËÌËÌ„ Á‡ ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl Ë ‰ÂÏÂ̈Ëfl. MINI-MENTAL STATE EXAMINATION (MMSE) MMSE  ¯ËÓÍÓ ËÁÔÓÎÁ‚‡Ì Ë ‰Ó͇Á‡Ì ‚ ÏÂʉÛ̇Ӊ̇ڇ Ô‡ÍÚË͇ ÚÂÒÚ, ‡Á‡·ÓÚÂÌ ÓÚ Folstein ÔÂÁ 1975 „. íÓÈ Â ÎÂÒÂÌ Á‡ ӂ·‰fl‚‡ÌÂ Ë ÔË·„‡ÌÂ, ÔÓ‚Âʉ‡ÌÂÚÓ ÏÛ Ó·ËÍÌÓ‚ÂÌÓ ËÁËÒÍ‚‡ Ì Ôӂ˜ ÓÚ 5-10 ÏËÌÛÚË. ÇÍβ˜‚‡ ÍÓÏÔÓÌÂÌÚË, ËÁÒΉ‚‡˘Ë ‡Á΢ÌË ÍÓ„ÌËÚË‚ÌË Ó·Î‡ÒÚË, ‚ Ú.˜. ÓËÂÌÚ‡ˆËfl Á‡ ‚ÂÏÂ Ë ÏflÒÚÓ, Ô‡ÏÂÚ, ‚ÌËχÌËÂ, ÒÏflÚ‡ÌÂ, ˜, „ÌÓÁËÒ, Ô‡ÍÒËÒ. êÂÁÛÎÚ‡Ú˙Ú ÔË MMSE ‚‡Ë‡ ÏÂÊ‰Û 0 Ë 30 ÚÓ˜ÍË, ͇ÚÓ ÔÓ-ÌËÒÍËflÚ Ò‚Ë‰ÂÚÂÎÒÚ‚‡ Á‡ ÔÓ-ÚÂÊÍÓ Û‚Âʉ‡ÌÂ. ê‡Á‡·ÓÚÂÌË Ò‡ ‚ÂÒËË Á‡ ÔË·„‡Ì ÔÓ ÚÂÎÂÙÓ̇ , ͇ÍÚÓ Ë Á‡ ËÁÒΉ‚‡Ì ̇ Îˈ‡ Ò Û‚‰ÂÌÓ ÁÂÌË . ç‰ÓÒÚ‡Ú˙Í Ì‡ MMSE  Á‡‚ËÒËÏÓÒÚÚ‡ ̇ ÂÁÛÎÚ‡Ú‡ ÓÚ ÌË‚ÓÚÓ Ì‡ Ó·‡ÁÓ‚‡ÌËÂ Ë ÂÁËÍÓ‚ËÚ ÔÓÁ̇ÌËfl ̇ ËÁÒΉ‚‡ÌËÚ Îˈ‡. Ç˙‚ ‚˙Á͇ Ò ÚÓ‚‡ Ò‡ ËÁ‡·ÓÚÂÌË ÌÓχÚË‚ÌË Ú‡·ÎˈË, ÍÓËÚÓ ÔÓÁ‚ÓÎfl‚‡Ú ÍÓÂ͈Ëfl ̇ ÂÁÛÎÚ‡Ú‡ Ë ÔÓÒÚË„‡Ì ̇ ÔÓ-„ÓÎflχ ‰ÓÒÚÓ‚ÂÌÓÒÚ. Ç˙ÁÏÓÊÌÓ Â Ó·‡˜Â ڇ͇‚‡ ÍÓÂ͈Ëfl ‰‡ ̇χÎË Á̇˜ËÚÂÎÌÓ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚÚ‡ ̇ ÚÂÒÚ‡ Ë ‰‡ ‰Ó‚‰ ‰Ó ÔÓÔÛÒ͇Ì ̇ Ô‡ˆËÂÌÚË Ò ÎÂ͇ ‰ÂÏÂ̈Ëfl, ‚˙ÔÂÍË ˜Â, ÓÚ ‰Û„‡ ÒÚ‡Ì‡, ÛÏÂÂÌÓ Û‚Â΢‡‚‡ ÒÔˆËÙ˘ÌÓÒÚÚ‡. ë‡‚ÌËÚÂÎÌÓ ÌËÒÍËÚ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ Ë ÒÔˆËÙ˘ÌÓÒÚ Ì‡ MMSE ÌÂfl‰ÍÓ Ò ÔÓÒÓ˜‚‡Ú ͇ÚÓ ÓÒÌÓ‚ÌË ÌÂ„Ó‚Ë Ò··ÓÒÚË. èË Ô‡„Ó‚‡ ÒÚÓÈÌÓÒÚ 24 ÚÓ˜ÍË, O'Connnor Ë Ò˙‡‚Ú., ËÁÒΉ‚‡ÈÍË 2302 Îˈ‡, ̇ÏË‡Ú ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ 86% Ë ÒÔˆËÙ˘ÌÓÒÚ 92% . èË Ò˙˘‡Ú‡ Ô‡„Ó‚‡ ÒÚÓÈÌÓÒÚ, ÔË ËÁÒΉ‚‡Ì ̇ 8949 Îˈ‡, McDowell Ë Ò˙‡‚Ú. ÔÓÎÛ˜‡‚‡Ú Ò˙ÓÚ‚ÂÚÌÓ 63% Ë 89%., ‡ ÔË 25 ÚÓ˜ÍË – 86% Ë 77%. èË·„‡Ì ‚ ÔÓ‰˙ÎÊÂÌË ̇ ÚË ‰ÂÒÂÚËÎÂÚËfl, MMSE  Ô‚‰ÂÌ Ì‡ ÏÌÓÊÂÒÚ‚Ó ÂÁˈË, ‚ Ú.˜. ·˙΄‡ÒÍË, ËÁÔÓÎÁ‚‡ Ò ÔÓ‚ÒÂÏÂÒÚÌÓ, ÔÓ‡‰Ë ÍÓÂÚÓ, ‚˙ÔÂÍË ÓÒÔÓ‚‡Ì‡Ú‡ ÒË ÔˆËÁÌÓÒÚ Ë Ì‰ÓÒÚ‡Ú˙˜Ì‡ ËÌÙÓχÚË‚ÌÓÒÚ, Ò  Ô‚˙̇Π‚ Òڇ̉‡ÚÂÌ ÓËÂÌÚË Á‡ Ò˙ÒÚÓflÌËÂÚÓ Ì‡ ÍÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË. íÓÈ ÏÓÊ ‰‡ ·˙‰Â ÓÒÓ·ÂÌÓ ÔÓÎÂÁÂÌ ÔË ËÁÒΉ‚‡Ì ̇ Ô‡ˆËÂÌÚË Ò Ôӂ˯ÂÌ ËÒÍ ÓÚ ‰ÂÏÂ̈Ëfl, ̇Ô. Ú‡ÍË‚‡ Ò ÎÂÍË ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl. èÓ‡‰Ë ÔÓÒÓ˜ÂÌËڠ̉ÓÒÚ‡Ú˙ˆË, ÌflÍÓË ‡‚ÚÓË Ô‰·„‡Ú MMSE ‰‡ Ò ËÁÔÓÎÁ‚‡ ‚ Ò˙˜ÂÚ‡ÌËÂ Ò ‰Û„Ë ÚÂÒÚÓ‚Â Ë Ò͇ÎË.

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MEMORY IMPAIRMENT SCREEN (MIS) MIS  ‡Á‡·ÓÚÂÌ ÓÚ Buschke Ë Ò˙ÚÛ‰ÌËˆË ÔÂÁ 1999 „. Ë Ô‰ÒÚ‡‚Îfl‚‡ Í‡Ú˙Í ÚÂÒÚ Á‡ ̇Û¯ÂÌËfl ̇ Ô‡ÏÂÚÚ‡, ËÁÒΉ‚‡˘ ÒÔÓÌÚ‡ÌÌÓÚÓ ÔËÔÓÏÌflÌÂ Ë ÔËÔÓÏÌflÌÂÚÓ ÒΉ ÔÓ‰ÔÓχ„‡ÌÂ. íÓÈ ÏÓÊ ‰‡ Ò ÔË·„‡ ‚˙‚ ‚ËÁÛ‡Î̇ ËÎË ÒÎÛıÓ‚‡ ÙÓχ, ΢ÌÓ ËÎË ÔÓ ÚÂÎÂÙÓ̇, ËÁÔÓÎÁ‚‡ÈÍË Â‰Ì‡ Ë Ò˙˘‡ ÚÂÒÚÓ‚‡ Ôӈ‰Û‡. è‰̇Á̇˜ÂÌ Â Ì‡È‚Â˜Â Á‡ ÒÍËÌËÌ„ ̇ ÅÄ Ë ‰Û„Ë ‰ÂÏÂ̈ËË, ÔË ÍÓËÚÓ Ô‡ÏÂÚÓ‚ËÚ ̇Û¯ÂÌËfl Ò ÔÓfl‚fl‚‡Ú ‡ÌÓ ‚ ıÓ‰‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ. êÂÁÛÎÚ‡Ú˙Ú ‚‡Ë‡ ÓÚ 0 ‰Ó 8 ÚÓ˜ÍË, ͇ÚÓ ÔÓÌËÒÍËflÚ Ò‚Ë‰ÂÚÂÎÒÚ‚‡ Á‡ ̇΢ˠ̇ ÔÓ-ÚÂÊÍË Ì‡Û¯ÂÌËfl. MIS ÔÓ͇Á‚‡ ‚ËÒÓÍË ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ (86%) Ë ÒÔˆËÙ˘ÌÓÒÚ (97%) ÔË Ò‡ÏÓÒÚÓflÚÂÎÌÓ ÔËÎÓÊÂÌËÂ, ÍÓÂÚÓ ‰Ó͇Á‚‡ Ì„ӂ‡Ú‡ ̇‰ÂʉÌÓÒÚ Í‡ÚÓ ÒÍËÌËÌ„Ó‚ ËÌÒÚÛÏÂÌÚ Á‡ ÅÄ Ë ‰Û„Ë ‰ÂÏÂ̈ËË ‚ ÍÎËÌ˘̇ڇ Ë Ó·˘‡Ú‡ Ô‡ÍÚË͇. è‰ËÏÒÚ‚‡Ú‡ ̇ ÚÂÒÚ‡ Ó˜ÂÚ‡‚‡Ú ‚ÂÓflÚÌÓÚÓ ÏÛ ÛÚ‚˙ʉ‡‚‡Ì ‚ ·ÎËÁÍÓ ·˙‰Â˘Â ͇ÚÓ ÓÒÌÓ‚ÂÌ ÒÍËÌËÌ„Ó‚ ËÌÒÚÛÏÂÌÚ ‚ Ô‡ÍÚË͇ڇ Ë ‚ „ÓÎÂÏË ÂÔˉÂÏËÓÎӄ˘ÌË ÔÓÛ˜‚‡ÌËfl. íÖëí ë êàëìÇÄçÖ çÄ óÄëéÇçàä (CLOCK DRAWING TEST, CDT) éÒÌÓ‚ÌÓÚÓ ËÁËÒÍ‚‡Ì ÔË ‡Á΢ÌËÚ ‚‡ˇÌÚË Ì‡ ÚÓÁË ÚÂÒÚ Â ËÁÒΉ‚‡ÌÓÚÓ Îˈ ‰‡ ̇ËÒÛ‚‡ ˆËÙÂ·Î‡Ú‡ ̇ ˜‡ÒÓ‚ÌËÍ Ë ÒÚÂÎÍËÚÂ, ÔÓ͇Á‚‡˘Ë ÓÔ‰ÂÎÂÌÓ ‚ÂÏ – ̇È-˜ÂÒÚÓ 11:10 ˜. éˆÂÌfl‚‡ÌÂÚÓ ÏÓÊ ‰‡ Ò ËÁ‚˙¯Ë ÔÓ ÌflÍÓÎÍÓ ÒËÒÚÂÏË, Ô‰ÎÓÊÂÌË ÓÚ ‡Á΢ÌË ‡‚ÚÓË. äÓ„‡ÚÓ CDT Ò ÔË·„‡ Ò‡ÏÓÒÚÓflÚÂÎÌÓ, ÂÁÛÎÚ‡ÚËÚ ·Ë ÒΉ‚‡ÎÓ ‰‡ Ò ËÌÚÂÔÂÚË‡Ú Ò Ôӂ˯ÂÌÓ ‚ÌËχÌËÂ, Ú˙È Í‡ÚÓ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚÚ‡ ̇ ÚÂÒÚ‡ ÔË ÎÂ͇ ‰ÂÏÂ̈Ëfl Ì  ‰ÓÒÚ‡Ú˙˜ÌÓ ‚ËÒÓ͇. CDT ·Ë ÏÓ„˙Î ‰‡ Ò ÔË·„‡ ͇ÚÓ ‰ÓÔ˙ÎÌÂÌË ̇ MMSE, Ôӂ˯‡‚‡ÈÍË ‰ÓÒÚÓ‚ÂÌÓÒÚÚ‡ Ë ÔÓ„ÌÓÒÚ˘̇ڇ ÒÚÓÈÌÓÒÚ Ì‡ ËÁÒΉ‚‡ÌÂÚÓ. èÓ‡‰Ë Ò‚ÓflÚ‡ Í‡ÚÍÓÒÚ, ÎÂÒÌÓÚ‡ ̇ ÔË·„‡ÌÂ Ë ÓÚÌÓÒËÚÂÎ̇ ÌÂÁ‡‚ËÒËÏÓÒÚ ÓÚ ÂÁËÍÓ‚Ë ÒÔÓÒÓ·ÌÓÒÚË, ÍÛÎÚÛÌË Ë ÂÚÌ˘ÂÒÍË Ù‡ÍÚÓË, CDT  ۉӷÂÌ Á‡ ËÁÔÓÎÁ‚‡Ì ÔË ÒÍËÌËÌ„. Ç ÚÂÒÚ‡ Mini-Cog ËÒÛ‚‡ÌÂÚÓ Ì‡ ˜‡ÒÓ‚ÌËÍ Â ÍÓÏ·ËÌË‡ÌÓ Ò˙Ò Á‡‰‡˜‡ Á‡ ÒÔÓÌÚ‡ÌÌÓ ÔËÔÔÓÏÌflÌ ̇ ÚË ‰ÛÏË. àÁÒΉ‚‡ÌÂÚÓ ÓÚÌÂχ ÓÍÓÎÓ ÚË ÏËÌÛÚË. èÓ‰Ó·ÌÓ Ì‡ CDT, ÂÁÛÎÚ‡Ú˙Ú Â ÓÚÌÓÒËÚÂÎÌÓ ÌÂÁ‡‚ËÒËÏ ÓÚ Ó·‡ÁÓ‚‡ÌËÂÚÓ Ë ‚·‰ÂÂÌÂÚÓ Ì‡ ÂÁË͇. íÂÒÚ˙Ú Â ÔÓ͇Á‡Î ‰Ó·‡ ÂÙÂÍÚË‚ÌÓÒÚ ÔË ÓÚÍË‚‡Ì ̇ ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl, Ò ÔÓ-‰Ó·Ë ÂÁÛÎÚ‡ÚË ÓÚ MMSE, ÓÒÓ·ÂÌÓ ÔË ÒÎÛ˜‡Ë Ò ÅÄ. ISAACS SET TEST (IST) íÂÒÚ˙Ú Ì‡ Isaacs  Í‡Ú˙Í Ë ÓÔÓÒÚÂÌ ËÌÒÚÛÏÂÌÚ Á‡ ËÁÒΉ‚‡Ì ̇ ÍÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË, ÓÚ˜ËÚ‡˘ ͇Ú„ÓˇÎ̇ڇ ‚Â·‡Î̇ ÙÎÛˉÌÓÒÚ. éÚ ËÁÒΉ‚‡ÌËÚ Îˈ‡ Ò ËÁËÒÍ‚‡ Á‡ ÓÔ‰ÂÎÂÌÓ ‚ÂÏ ‰‡ ËÁ·ÓflÚ ÔÓÌflÚËfl, ÔË̇‰ÎÂʇ˘Ë Í˙Ï ˜ÂÚËË ‡Á΢ÌË, ‰Ó· ËÁ‚ÂÒÚÌË Í‡Ú„ÓËË – ˆ‚ÂÚÓ‚Â, ÊË‚ÓÚÌË, ÔÎÓ‰Ó‚Â Ë „‡‰Ó‚Â. óÂÒÚÓ ‚ Ô‡ÍÚË͇ڇ Ò ËÁÔÓÎÁ‚‡ ‚‡ˇÌÚ Ì‡ ÚÂÒÚ‡, ÔË ÍÓÈÚÓ Á‡ ËÁ·Ófl‚‡Ì ̇ ÔÓÌflÚËfl ÓÚ ‚Òfl͇ ͇Ú„ÓËfl Ò Ô‰ÓÒÚ‡‚flÚ ÔÓ 15 ÒÂÍÛ̉Ë. íÓÁË ‚‡ˇÌÚ Â ÔÓ͇Á‡Î ‚ËÒÓ͇ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ Í‡ÍÚÓ ÔË ÓÚÍË‚‡Ì ̇ ‰ÂÏÂ̈Ëfl, ڇ͇ Ë Í˙Ï ÓÚ˜Ëڇ̠̇ ÎÂÍË ÔÓÏÂÌË ‚ ÍÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË ‚˙‚ ‚ÂÏÂÚÓ. 7 MINUTE SCREEN (7MS) 7MS Ô‰ÒÚ‡‚Îfl‚‡ Í‡Ú͇ ·‡ÚÂËfl ÓÚ ˜ÂÚËË ÚÂÒÚ‡: ÓËÂÌÚ‡ˆËfl Á‡ ‚ÂÏÂ, ÔËÔÓÏÌflÌÂ Ò ÔÓ‰ÔÓχ„‡ÌÂ, ͇Ú„ÓˇÎ̇ ÙÎÛˉÌÓÒÚ Ë ËÒÛ‚‡Ì ̇ ˜‡ÒÓ‚ÌËÍ. èË ÒÍËÌËÌ„ Á‡ ‰ÂÏÂ̈Ëfl ÔÓ͇Á‚‡ Ò‰̇ ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ 92% Ë ÒÔˆËÙ˘ÌÓÒÚ 96%. èÓÎÛ˜ÂÌËÚ ‰Ó·Ë ÂÁÛÎÚ‡ÚË ÔË


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

ˉÂÌÚËÙˈË‡Ì ̇ ÎÂ͇ ÅÄ ÔÓÁ‚ÓÎfl‚‡Ú ‰‡ Ò ӷÒ˙ʉ‡ ÔËÎÓÊÂÌËÂÚÓ Ì‡ 7MS ÔË ‡Á„‡Ì˘‡‚‡Ì ̇ ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl, ‰˙Îʇ˘Ë Ò ̇ ‰ÂÏÂ̈Ëfl, ÓÚ ÔÓÏÂÌË ‚ ÍÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË, ̇ÒÚ˙Ô‚‡˘Ë ÔË ÌÓχÎÌËfl ÔÓˆÂÒ Ì‡ ÒÚ‡ÂÂÌÂ. ä˙Ï Ô‰ËÏÒÚ‚‡Ú‡ ̇ ·‡ÚÂËflÚ‡ ÒÔ‡‰‡Ú Ò˙˘Ó ·˙ÁÓÚÓ È Ó‚Î‡‰fl‚‡ÌÂ, Í‡ÚÍÓÒÚÚ‡ (7-8 ÏËÌÛÚË) Ë ÎËÔÒ‡Ú‡ ̇ ÌÂÓ·ıÓ‰ËÏÓÒÚ ÓÚ ÍÎËÌ˘̇ ÔˆÂÌ͇ ÔË Ú˙ÎÍÛ‚‡Ì ̇ ÂÁÛÎÚ‡Ú‡. THE GENERAL PRACTITIONER ASSESSMENT OF COGNITION (GPCOG) GPCOG  Ò˙Á‰‡‰ÂÌ ‚ ÓÔËÚ ‰‡ Ò ÓÚ„Ó‚ÓË Ì‡ ÌÂÓ·ıÓ‰ËÏÓÒÚÚ‡ ÓÚ ÒÍËÌËÌ„Ó‚ ÚÂÒÚ, ‡‰‡ÔÚË‡Ì Í˙Ï Ó·˘ÓÔ‡ÍÚËÍÛ‚‡˘ËÚ ÎÂ͇Ë. éÒ‚ÂÌ ÂÎÂÏÂÌÚË, ËÁÒΉ‚‡˘Ë ÍÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË Ì‡ Ô‡ˆËÂÌÚ‡, ÚÂÒÚ˙Ú Ò˙‰˙ʇ Ë ‚˙ÔÓÒË Í˙Ï Ì„ӂ ·ÎËÁ˙Í. Ç ÔÓÛ˜‚‡ÌÂ, ‚Íβ˜‚‡˘Ó 283 Ô‡ˆËÂÌÚË Ì‡ 67 ÒÂÏÂÈÌË ÎÂ͇Ë,  ÛÒÚ‡ÌÓ‚ÂÌÓ, ˜Â GPCOG  ̇‰ÂʉÂÌ ËÌÒÚÛÏÂÌÚ Á‡ ÓÚÍË‚‡Ì ̇ ‰ÂÏÂ̈Ëfl, Ò ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ 85% Ë ÒÔˆËÙ˘ÌÓÒÚ 86%. íÓÈ Â Í‡Ú˙Í, Ô‡ÍÚ˘ÂÌ Ë Ò ‚˙ÁÔËÂχ ‰Ó· ÓÚ Ô‡ˆËÂÌÚËÚÂ. THE FOUR IADL SCORE (4-IADL) àÌÒÚÛÏÂÌÚ‡ÎÌËÚ Âʉ̂ÌË ‰ÂÈÌÓÒÚË (Instrumental Activities of Daily Living, IADL) Ò‡ Ò‚˙Á‡ÌË Ò˙Ò ÒÔÓÒÓ·ÌÓÒÚÚ‡ Á‡ ‚Ó‰ÂÌ ̇ ÌÂÁ‡‚ËÒËÏ ÊË‚ÓÚ Ë ‚Íβ˜‚‡Ú ÒÔ‡‚flÌÂ Ò ÙË̇ÌÒËÚÂ, ÔË„ÓÚ‚flÌ ̇ ı‡Ì‡, Ô‡Á‡Û‚‡ÌÂ, ËÁÔÓÎÁ‚‡Ì ̇ Ú‡ÌÒÔÓÚÌË Ò‰ÒÚ‚‡, ËÁ‚˙¯‚‡Ì ̇ ‰ÓχÍËÌÒ͇ ‡·ÓÚ‡, ËÁÔÓÎÁ‚‡Ì ̇ ÚÂÎÂÙÓÌ Ë ‰. ç‡Î˘ËÂÚÓ Ì‡ Á‡ÚÛ‰ÌÂÌËfl ‚ ÓÒ˙˘ÂÒÚ‚fl‚‡ÌÂÚÓ Ì‡ ÔÓ‰Ó·ÌË ‰ÂÈÌÓÒÚË ‚ÒΉÒÚ‚Ë ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl  ÌÂÓ·ıÓ‰ËÏÓ ÛÒÎÓ‚Ë Á‡ ‰Ë‡„ÌÓÒÚˈË‡Ì ̇ ‰ÂÏÂ̈Ëfl. ìÒÚ‡ÌÓ‚ÂÌÓ Â, ˜Â Á‡ÚÛ‰ÌÂÌËflÚ‡ ‚ ˜ÂÚËË ÓÚ ÚÂÁË ‰ÂÈÌÓÒÚË Ò‡ ̇È-ÔÓ͇Á‡ÚÂÎÌË. í ҇ ‚Íβ˜ÂÌË ‚ Í‡Ú͇ Ò͇· Á‡ ËÌÒÚÛÏÂÌÚ‡ÎÌË Âʉ̂ÌË ‰ÂÈÌÓÒÚË ÔË ‰ÂÏÂ̈Ëfl (4IADL Score): ËÁÔÓÎÁ‚‡ÌÂÚÓ Ì‡ ÚÂÎÂÙÓÌ, Ôˉ‚ËÊ‚‡ÌÂÚÓ Ò Ô‚ÓÁÌË Ò‰ÒÚ‚‡, ÔËÂÏ˙Ú Ì‡ ωË͇ÏÂÌÚË Ë ÒÔ‡‚flÌÂÚÓ Ò˙Ò ÒÓ·ÒÚ‚ÂÌËÚ ÙË̇ÌÒË. ÇÒfl͇ ÓÚ ‰ÂÈÌÓÒÚËÚ ‚ Ò͇·ڇ Ò ӈÂÌfl‚‡ Ò 0 ËÎË 1 ÚӘ͇ ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ ÚÓ‚‡ ‰‡ÎË Ò ËÁ‚˙¯‚‡ Ò‡ÏÓÒÚÓflÚÂÎÌÓ ÓÚ Ë̉˂ˉ‡ ËÎË Ò‡ ̇Îˈ ‡Á΢ÌË ÔÓ ÒÚÂÔÂÌ Á‡ÚÛ‰ÌÂÌËfl. êÂÁÛÎÚ‡ÚËÚ ÓÚ ˜ÂÚËËÚ ‰ÂÈÌÓÒÚË Ò ÒÛÏË‡Ú, Á‡ ‰‡ Ò ÔÓÎÛ˜Ë Ó·˘ ÂÁÛÎÚ‡Ú ÓÚ Ò͇·ڇ. èË Ì‡Î˘Ë ̇ 1 ËÎË Ôӂ˜ ÚÓ˜ÍË Â ‚˙ÁÏÓÊÌÓ ‰‡ Ò ͇҇ Á‡ ‰ÂÏÂ̈Ëfl ËÎË ‰‡ Ò˙˘ÂÒÚ‚Û‚‡ „ÓÎflχ ‚ÂÓflÚÌÓÒÚ Á‡ ‡Á‚ËÚËÂÚÓ È. ëÚÓÈÌÓÒÚÚ‡ ̇ Ò͇·ڇ Ó·‡˜Â  Ì ÚÓÎÍÓ‚‡ Á‡ ˉÂÌÚËÙˈË‡Ì ̇ ÒÎÛ˜‡Ë ̇ ‰ÂÏÂ̈Ëfl, ‡ ÔÓ-ÒÍÓÓ ‰‡ ‰‡‰Â ̇ÒÓ͇ Á‡ ÔÓÒΉ‚‡˘Ó Ì‚ÓÔÒËıÓÎӄ˘ÌÓ ËÁÒΉ‚‡ÌÂ. è‰ÒÚ‡‚ÂÌËÚ ÍÓ„ÌËÚË‚ÌË ÚÂÒÚÓ‚Â Ò‡ Í‡ÚÍË, ÎÂÒÌË Á‡ ÔË·„‡Ì ‚ Ô‡ÍÚË͇ڇ, ‡ Ó·Û˜ÂÌËÂÚÓ, ÍÓÂÚÓ Ò ËÁËÒÍ‚‡ Á‡ ‡·ÓÚ‡ Ò Úflı,  ÏËÌËχÎÌÓ. àÁÔÓÎÁ‚‡ÌÂÚÓ ËÏ Á‡ ÒÍËÌËÌ„, ̇È-‚˜ ̇ÒÓ˜ÂÌÓ Í˙Ï Îˈ‡ Ò˙Ò ÒÛ·ÂÍÚË‚ÌË ÓÔ·͂‡ÌËfl ÓÚ Ì‡Û¯ÂÌËfl ̇ Ô‡ÏÂÚÚ‡ ËÎË ‰Û„Ë ÍÓ„ÌËÚË‚ÌË ÙÛÌ͈ËË, ·Ë ‰ÓÔËÌÂÒÎÓ Á‡ ˉÂÌÚËÙˈË‡Ì ̇ Á̇˜ËÚÂÎ̇ ˜‡ÒÚ ÓÚ ·˙‰Â˘ËÚ ÒÎÛ˜‡Ë Ò ‰ÂÏÂ̈Ëfl, ÔË ÚÓ‚‡ ‚ ÒÚ‡‰Ëfl, ÍÓ„‡ÚÓ Î˜ÂÌËÂÚÓ Â Ì‡È-ÂÙÂÍÚË‚ÌÓ. Ç˙ÔÂÍË ˜Â ÌflÍÓË ÓÚ Ò͇ÎËÚ ËÏ‡Ú Ò‡‚ÌËÚÂÎÌÓ ‚ËÒÓÍË ˜Û‚ÒÚ‚ËÚÂÎÌÓÒÚ Ë ÒÔˆËÙ˘ÌÓÒÚ, Ú Ì ·Ë ÒΉ‚‡ÎÓ ‰‡ Ò ËÁÔÓÎÁ‚‡Ú Ò‡ÏÓÒÚÓflÚÂÎÌÓ Á‡ ÔÓÒÚ‡‚flÌ ̇ ‰Ë‡„ÌÓÁ‡, ‡ Á‡ ̇ÒÓ˜‚‡Ì ̇ ÔÓ‰ıÓ‰fl˘Ëfl ÍÓÌÚËÌ„ÂÌÚ Í˙Ï ÔÓ‰Ó·ÌÓ Ì‚ÓÔÒËıÓÎӄ˘ÌÓ Ë ÍÎËÌ˘ÌÓ ËÁÒΉ‚‡Ì ‚ Ò˙ÓÚ‚ÂÚÌË ÒÔˆˇÎËÁË‡ÌË Á‚Â̇. ãàíÖêÄíìêÄ 1. 2.

í‡ÈÍÓ‚ ã. ê‡Ì̇ ‰Ë‡„ÌÓÁ‡ ÔË ·ÓÎÂÒÚÚ‡ ̇ ÄΈı‡ÈÏÂ Ë Ò˙‰Ó‚‡Ú‡ ‰ÂÏÂ̈Ëfl. ëÓÙËfl: 2006. Andrew M. Screening for Dementia in Primary Care: Who, When and How. The Canadian Alzheimer Disease Review 2000; 4(1):4-7.

3.

4. 5. 6. 7. 8. 9. 10.

11. 12. 13. 14. 15. 16.

17. 18. 19. 20. 21. 22. 23. 24. 25. 26.

27. 28. 29.

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Barberger-Gateau P, Commenges D, Gagnon M, Letenneur L, Sauvel C, Dartigues JF. Instrumental activities of daily living as a screening tool for cognitive impairment and dementia in elderly community dwellers. J Am Geriatr Soc 1992; 40(11):1129-1134. Barberger-Gateau P, Fabrigoule C, Helmer C, Rouch I, Dartigues JF. Functional impairment in instrumental activities of daily living: an early clinical sign of dementia? J Am Geriatr Soc 1999; 47(4):456-462. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11):1021-1027. Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Simplifying detection of cognitive impairment: comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample. J Am Geriatr Soc 2005; 53(5):871-874. Boustani M, Peterson B, Hanson L, Harris R, Lohr KN. Screening for dementia in primary care: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003; 138(11):927-937. Brodaty H, Pond D, Kemp NM et al. The GPCOG: a new screening test for dementia designed for general practice. J Am Geriatr Soc 2002; 50(3):530534. Buschke H, Kuslansky G, Katz M et al. Screening for dementia with the Memory Impairment Screen. Neurology 1999; 52(2):231. Busse A, Sonntag A, Bischkopf J, Matschinger H, Angermeyer MC. Adaptation of dementia screening for vision-impaired older persons: administration of the Mini-Mental State Examination (MMSE). J Clin Epidemiol 2002; 55(9):909-915. Chertkow H, Bergman H, Schipper HM et al. Assessment of suspected dementia. Can J Neurol Sci 2001; 28 Suppl 1:S28-S41. Connor DJ, Seward JD, Bauer JA, Golden KS, Salmon DP. Performance of three clock scoring systems across different ranges of dementia severity. Alzheimer Dis Assoc Disord 2005; 19(3):119-127. Cossa FM, Della SS, Musicco M, Spinnler H, Ubezio MC. Comparison of two scoring systems of the Mini-Mental State Examination as a screening test for dementia. J Clin Epidemiol 1997; 50(8):961-965. Cromwell DA, Eagar K, Poulos RG. The performance of instrumental activities of daily living scale in screening for cognitive impairment in elderly community residents. J Clin Epidemiol 2003; 56(2):131-137. Dalla Barba G, Traykov L, Baudic S. Neuropsychological Examination In Dementia. In: Aminoff MJ, Boller F, Swaab DF, editors. Handbook of Clinical Neurology, 3rd edition. Amsterdam: Elsevier, 2006. Ferrucci L, Cecchi F, Guralnik JM et al. Does the Clock Drawing Test predict cognitive decline in older persons independent of the Mini-Mental State Examination? The FINE Study Group. Finland, Italy, The Netherlands Elderly. J Am Geriatr Soc 1996; 44(11):1326-1331. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3):189-198. Gauthier S. Screening for Dementia: How and Why? The Canadian Alzheimer Disease Review 2002; 5(2):18-20. Isaacs B, Akhtar AJ. The set test: a rapid test of mental function in old people. Age Ageing 1972; 1(4):222-226. Kuslansky G, Buschke H, Katz M, Sliwinski M, Lipton RB. Screening for Alzheimer's disease: the memory impairment screen versus the conventional three-word memory test. J Am Geriatr Soc 2002; 50(6):1086-1091. Lezak M, Howleson D, Loring D. Neuropsychological Assessment. 4 ed. New York: Oxford University Press, 2004. Lovestone S, Gauthier S. Management of Dementia. London: Martin Dunitz, 2001. McDowell I, Kristjansson B, Hill GB, Hebert R. Community screening for dementia: the Mini Mental State Exam (MMSE) and Modified Mini-Mental State Exam (3MS) compared. J Clin Epidemiol 1997; 50(4):377-383. O'Connor DW, Pollitt PA, Hyde JB et al. The reliability and validity of the Mini-Mental State in a British community survey. J Psychiatr Res 1989; 23(1):87-96. Paganini-Hill A, Clark LJ, Henderson VW, Birge SJ. Clock drawing: analysis in a retirement community. J Am Geriatr Soc 2001; 49(7):941-947. Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56(9):1133-1142. Proust-Lima C, Amieva H, Dartigues JF, Jacqmin-Gadda H. Sensitivity of Four Psychometric Tests to Measure Cognitive Changes in Brain AgingPopulation-based Studies. Am J Epidemiol 2006. Roccaforte WH, Burke WJ, Bayer BL, Wengel SP. Validation of a telephone version of the mini-mental state examination. J Am Geriatr Soc 1992; 40(7):697-702. Solomon PR, Hirschoff A, Kelly B et al. A 7 Minute Neurocognitive Screening Battery Highly Sensitive to Alzheimer's Disease. Arch Neurol 1998; 55(3):349-355.

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: Ñ- à‚‡Ì ÑËÏËÚÓ‚ ìåÅÄã ◊ë‚ÂÚ‡ å‡Ë̇”, è˙‚‡ ÍÎËÌË͇ ÔÓ ÌÂ‚ÌË ·ÓÎÂÒÚË 9010 LJ̇, ÛÎ. ïËÒÚÓ ëÏËÌÂÌÒÍË 1 íÂÎ./î‡ÍÒ: 052/306101 E-mail: indimitrov@yahoo.com


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

77

éË„Ë̇ÎÌË ÒÚ‡ÚËË ãÖäà äéÉçàíàÇçà çÄêìòÖçàü èêà èÄñàÖçíà ë èÄêäàçëéçéÇÄ ÅéãÖëí èÂÚÓ‚‡ å, ê‡È˜Â‚‡ å, ÜÂ΂ ü, í‡ÈÍÓ‚ ã. ìåÅÄã “ÄÎÂÍ҇̉Ó‚Ò͇”, äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl, å‰ˈËÌÒÍË ìÌË‚ÂÒËÚÂÚ, ëÓÙËfl SUMMARY MILD COGNITIVE IMPAIRMENT IN PATIENTS WITH PARKINSON’S DESEASE M. Petrova, M. Raycheva, Y. Zhelev, L. Traykov In recent years, practical as well as theoretical considerations have engendered a strong interest in recognizing Parkinson’s disease dementia (PDD) at a very early stage. Recent study suggested that onset of PDD is preceded by a phase known as Parkinson’s disease mild cognitive impairment (PD-MCI). However, the exact pattern of MCI in patients with PD (PD-MCI) is still unclear and subject of considerable controversy. The objective of this study was to determine the pattern of mild cognitive impairment in patients with Parkinson’s disease. We investigated 47 patients with PD-MCI and 25 normal controls. All subjects underwent a comprehensive neuropsychological assessment including tests of episodic memory, language, constructional praxis, psychomotor speed, attention and executive functions, as well as quantitative ratings of motor symptom severity and functional status. MCI was diagnosed in nondemented patients who had cognitive impairment based on neuropsychological testing and no functional impairment. Relative to controls, PD-MCI group showed significant deficits in immediate recall of the Free and Cued Selective Reminding Test, phonemic and semantic fluencies, psychomotor speed, cognitive sequencing and working memory. However, this group was unimpaired in recognition memory, long-term forgetting, naming, concept-formation and constructional praxis. In conclusion deficits in episodic memory, attention and executive function are most prominent features in cognitive profile in PD-MCI patients, relative to other cognitive domains. The results are in agreement with the studies emphasizing the importance of frontal subcortical dysfunction in PD. The possible relationship between MCI and incipient dementia in individuals with PD remains to be investigated in follow-up studies. KEY WORDS: Parkinson’s disease dementia, early diagnosis, Parkinson’s disease mild cognitive impairment, neuropsychology. êÖáûåÖ èÂÁ ÔÓÒΉÌËÚ „Ó‰ËÌË ‰ˈ‡ ÍÎËÌ˘ÌË Ë ÚÂÓÂÚ˘ÌË Ô‰ÔÓÒÚ‡‚ÍË Ô‰ËÁ‚ËÍ‚‡Ú ÓÒÓ·ÂÌ ËÌÚÂÂÒ ÓÍÓÎÓ ‰Ë‡„ÌÓÁ‡Ú‡ ̇ ‰ÂÏÂ̈Ëfl ÔË è‡ÍËÌÒÓÌÓ‚‡Ú‡ ·ÓÎÂÒÚ (èÅ) ‚ ̇È-‡ÌÌËÚÂ È ÒÚ‡‰ËË. çÂÓÚ‰‡‚̇ Ò Ô‰ÔÓÎÓÊË Ì‡Î˘ËÂÚÓ Ì‡ Ô‰ÂÏÂÌÚÂÌ ÒÚ‡‰ËÈ Ì‡ Á‡·ÓÎfl‚‡ÌÂÚÓ, ËÁ‚ÂÒÚÂÌ Í‡ÚÓ ÎÂÍÓ ÍÓ„ÌËÚË‚ÌÓ Ì‡Û¯ÂÌË ÔË èÅ (èÅ-ãäç). èË ‚Ò ÚÓ‚‡ ÚÓ˜ÌËflÚ ÏÓ‰ÂΠ̇ èÅ-ãäç  ‚Ò Ӣ ÌÂflÒÂÌ Ë Â Ó·ÂÍÚ Ì‡ Á̇˜ËÚÂÎÌË ÔÓÚË‚Ó˜Ëfl. ñÂÎÚ‡ ̇ ̇ÒÚÓfl˘ÓÚÓ ÔÓÛ˜‚‡Ì  ‰‡ Ò ÓÔ‰ÂÎË ÔÓÙË· ̇ ÎÂÍË ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl ÔË Ô‡ˆËÂÌÚË Ò èÅ. çË ËÁÒΉ‚‡Ï 47 Ô‡ˆËÂÌÚË Ò èÅ-ãäç Ë 25 ÌÓχÎÌË ÍÓÌÚÓÎË. ÇÒ˘ÍË Û˜‡ÒÚÌËˆË Ò‡ ËÁÒΉ‚‡ÌË Ò ÔÓ‰ӷ̇

Ì‚ÓÔÒËıÓÎӄ˘̇ ·‡ÚÂËfl, ‚Íβ˜‚‡˘‡ ÚÂÒÚÓ‚Â Á‡ ÂÔËÁӉ˘̇ Ô‡ÏÂÚ, ˜, ÍÓÌÒÚÛÍÚË‚ÂÌ Ô‡ÍÒËÒ, ÔÒËıÓÏÓÚÓ̇ ÒÍÓÓÒÚ, ‚ÌËχÌËÂ Ë ÂÍÁÂÍÛÚË‚ÌË ÙÛÌ͈ËË. ãäç Ò‡ ‰Ë‡„ÌÓÒÚˈË‡ÌË ÔË Ì‰ÂÏÂÌÚÌË Ô‡ˆËÂÌÚË, ÍÓËÚÓ ËÏ‡Ú ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl Ë ÌflÏ‡Ú ÙÛÌ͈ËÓ̇ÎÂÌ ‰ÂÙˈËÚ. Ç Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎËÚ ԇˆËÂÌÚËÚÂ Ò èÅ-ãäç ÔÓ͇Á‚‡Ú Á̇˜ËÚÂÎÂÌ ‰ÂÙˈËÚ ‚ ÌÂÔÓÒ‰ÒÚ‚ÂÌÓÚÓ Ë ÓÚ‰‡Î˜ÂÌÓ Ò‚Ó·Ó‰ÌÓ ÔËÔÓÏÌflÌ ÔË Free and Cued Selective Reminding Test, ‚Â·‡Î̇ڇ ÙÎÛˉÌÓÒÚ, ÔÒËıÓÏÓÚÓ̇ڇ ÒÍÓÓÒÚ, ÍÓ„ÌËÚË‚ÌÓÚÓ ÔÓÒΉfl‚‡ÌÂ Ë ‡·ÓÚ̇ڇ Ô‡ÏÂÚ. í‡ÁË „ÛÔ‡ Ó·‡˜Â ÔÓ͇Á‚‡ ÌÓχÎÌË ÂÁÛÎÚ‡ÚË ÔË ‡ÁÔÓÁ̇‚‡ÌÂÚÓ, ÓÚ‰‡Î˜ÂÌÓÚÓ Ó·˘Ó ÔËÔÓÏÌflÌÂ, ̇ÁÓ‚‡‚‡ÌÂÚÓ, ÍÓ̈ÂÔÚÛ‡ÎËÁ‡ˆËflÚ‡ Ë ÍÓÌÒÚÛÍÚË‚ÌËfl Ô‡ÍÒËÒ. Ç Á‡Íβ˜ÂÌË ‰ÂÙˈËÚËÚ ‚ ÂÔËÁӉ˘̇ڇ Ô‡ÏÂÚ, ‚ÌËχÌËÂÚÓ Ë ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË Ò‡ ̇È-ËÁ‡ÁÂÌËÚ ˜ÂÚË Ì‡ ÍÓ„ÌËÚË‚ÌËfl ÔÓÙËΠ̇ Ô‡ˆËÂÌÚËÚÂ Ò èÅãäç. èÓÎÛ˜ÂÌËÚ ÓÚ Ì‡Ò ÂÁÛÎÚ‡ÚË Ò‡ ‚ Ò˙ÓÚ‚ÂÚÒÚ‚ËÂ Ò ÔÓÛ˜‚‡ÌËfl, ÔÓ‰˜ÂÚ‡‚‡˘Ë ‚‡Ê̇ڇ ÓÎfl ̇ ÙÓÌÚ‡ÎÌÓ ÒÛ·ÍÓÚË͇Î̇ ‰ËÒÙÛÌ͈Ëfl ÔË èÅ. Ç˙ÁÏÓÊ̇ڇ ‚˙Á͇ ÏÂÊ‰Û ãäç Ë Ì‡˜‡Î̇ ‰ÂÏÂ̈Ëfl ÔË ËÌ‰Ë‚Ë‰Ë Ò èÅ ÓÒÚ‡‚‡ ‰‡ ·˙‰Â ËÁÒΉ‚‡Ì‡ ‚ ÔÓÒΉ‚‡˘Ë ÔÓÛ˜‚‡ÌËfl. äãûóéÇà Ñìåà: ‰ÂÏÂ̈Ëfl ÔË è‡ÍËÌÒÓÌÓ‚‡ ·ÓÎÂÒÚ, ‡Ì̇ ‰Ë‡„ÌÓÁ‡, ÎÂÍÓ ÍÓ„ÌËÚË‚ÌÓ Ì‡Û¯ÂÌË ÔË è‡ÍËÌÒÓÌÓ‚‡ ·ÓÎÂÒÚ, Ì‚ÓÔÒËıÓÎÓ„Ëfl. äÓ̈ÂÔˆËflÚ‡ Á‡ ãÂÍÓÚÓ äÓ„ÌËÚË‚ÌÓ ç‡Û¯ÂÌË (ãäç)  Ô‰ÎÓÊÂ̇ ‰‡ Á‡Ô˙ÎÌË ÔÂıÓ‰‡ ÏÂÊ‰Û ÌÓχÎÌÓÚÓ ÒÚ‡ÂÂÌÂ Ë ‰ÂÏÂ̈ËflÚ‡ (15,14). ëÚËÍÚÌÓÚÓ ÔËÎÓÊÂÌË ̇ Ô˙‚Ó̇˜‡Î̇ڇ ‰ÂÙËÌˈËfl ̇ ãäç ÔÓ͇Á‚‡ ÔÂÁ ÔÓÒΉÌËÚ „Ó‰ËÌË, ˜Â Ò ͇҇ ÔÓ-ÒÍÓÓ Á‡ ıÂÚÂÓ„ÂÌ̇ Ë ÌÂÒÚ‡·ËÎ̇ ÔÓ ÓÚÌÓ¯ÂÌË ̇ ÔÓ„ÂÒËflÚ‡ ÒË „ÛÔ‡ (16). óÂÚËË ‡Á΢ÌË ÔÓ‰ÚËÔ‡ ̇ ãäç ·flı‡ ÓÔËÒ‡ÌË Ì‡ÒÍÓÓ (14). èË̈ËÔÌËÚ ‡Á΢Ëfl ÏÂÊ‰Û ÚÂÁË „ÛÔË Ò‡ ̇΢ËÂÚÓ ËÎË ÎËÔÒ‡Ú‡ ̇ Ô‡ÏÂÚÓ‚Ë Ì‡Û¯ÂÌËfl (‡ÏÌÂÒÚ˘ÂÌ ÒÂ˘Û Ì‡ÏÌÂÒÚ˘ÂÌ), ͇ÍÚÓ Ë Ì‡Û¯ÂÌËfl ‚ ‰̇ ËÎË ÏÌÓÊÂÒÚ‚Ó ÍÓ„ÌËÚË‚ÌË Ó·Î‡ÒÚË. Ç˙ÔÂÍË ˜Â ãäç ÏÓÊ ‰‡ Ò Ô‰ÒÚ‡‚Ë ‚ ‡ÁÌÓÓ·‡Á̇ ÍÓÏ·Ë̇ˆËfl ÓÚ ÒËÏÔÚÓÏË, ÍÓ„‡ÚÓ Ì‡Û¯ÂÌËÂÚÓ ‚ Ô‡ÏÂÚÚ‡  ‚Ӊ¢ËflÚ ÒËÏÔÚÓÏ, Ò ͇҇ Á‡ ‡ÏÌÂÒÚ˘ÂÌ ÔÓ‰ÚËÔ ãäç (‡ãäç). àÏÂÌÌÓ ÚÓÁË ÚËÔ ãäç Ò ҂˙Á‚‡ Ò Ôӂ˯ÂÌ ËÒÍ ÓÚ ‡Á‚ËÚË ̇ ·ÓÎÂÒÚ Ì‡ ÄΈı‡ÈÏÂ (ÅÄ) (15). äÓ„ÌËÚË‚ÌËÚ ̇Û¯ÂÌËfl Ò‡ ˜ÂÒÚÓ Ò¢‡ÌË Ë ÔË Ô‡ˆËÂÌÚË Ò è‡ÍËÌÒÓÌÓ‚‡Ú‡ ·ÓÎÂÒÚ (èÅ), ‰ÓË Ë ÔË ÌӂӉˇ„ÌÓÒÚˈË‡ÌËÚ ÒÎÛ˜‡Ë (13). ë˙‚ÂÏÂÌÌËÚ ÔÓÛ˜‚‡ÌËfl ÒÓ˜‡Ú, ˜Â ˜ÂÒÚÓÚ‡Ú‡ ̇ ÍÓ„ÌËÚË‚ÌËÚ ̇Û¯ÂÌËfl ÔË Ì‰ÂÏÂÌÚÌË Ô‡ˆËÂÌÚË Ò èÅ Â 70% (7), ‡ ˜ÂÒÚÓÚ‡Ú‡ ̇ ‰ÂÏÂ̈ËflÚ‡ ÓÚ 20% ‰Ó ̇‰ 40% (8,2). êËÒÍ˙Ú Á‡ ‡Á‚ËÚË ̇ ‰ÂÏÂ̈Ëfl ÔË Ô‡ˆËÂÌÚË Ò èÅ Â 6 Ô˙ÚË ÔÓ-‚ËÒÓÍ ‚ Ò‡‚ÌÂÌË Ò˙Ò Ò˙ÓÚ‚ÂÚÌË ÔÓ ‚˙Á‡ÒÚ Á‰‡‚Ë Îˈ‡ (1). äÓ̈ÂÔˆËflÚ‡ Á‡ ãäç ͇ÚÓ ÔÓ‰ÓÏ Ì‡ ÅÄ ‰‡‰Â ÓÒÌÓ‚‡ÌË ‰‡ Ò Ô‰ÔÓÎÓÊË, ˜Â è‡ÍËÌÒÓÌÓ‚‡Ú‡ ‰ÂÏÂ̈Ëfl Ò Ô‰¯ÂÒÚ‚‡ Ò˙˘Ó ÓÚ ÒÚ‡‰ËÈ Ì‡ ãäç (èÅ-ãäç). éÚ Ôӂ‰ÂÌÓ, Á‡ Ò„‡ ‰ËÌÒÚ‚ÂÌÓ, ÔÓÛ˜‚‡Ì ‚˙ıÛ Ô‡ˆËÂÌÚË Ò èÅ-ãäç Ò ÛÒÚ‡ÌÓ‚fl‚‡, ˜Â ˜ÂÒÚoÚ‡Ú‡ ̇ ÔÓ„ÂÒËfl ‰Ó ‰ÂÏÂ̈Ëfl  ÔË·ÎËÁËÚÂÎÌÓ 15% „Ӊ˯ÌÓ, ËÎË ‡‚̇ ̇


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

Ú‡ÁË ÔË ·ÓÎÂÒÚÚ‡ ̇ ÄΈı‡ÈÏÂ. è‰ÔÓ·„‡ Ò Ò˙˘ÂÒÚ‚Û‚‡ÌÂÚÓ Ì‡ ‡Á΢ÌË ÍÓ„ÌËÚË‚ÌË ÔÓÙËÎË ÔË èÅ (6). èӂ˜ÂÚÓ ‡‚ÚÓË ÔËÂχÚ, ˜Â ̇˜‡ÎÌËflÚ ÍÓ„ÌËÚË‚ÂÌ ‰ÂÙˈËÚ ÔË èÅ Â Ô‡ÏÂÚÓ‚ËflÚ, ‰Ó͇ÚÓ ‰Û„Ë Ò˜ËÚ‡Ú, ˜Â ‚Ó‰Â˘Ë Ò‡ ̇Û¯ÂÌËflÚ‡ ‚ ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË. ëÔˆËÙË͇ڇ ̇ ÍÓ„ÌËÚË‚ÌËfl ÔÓÙËÎ ÔË Ô‡ˆËÂÌÚË Ò èÅ-ãäç  ÌÂflÒ̇ Ë ÔÓ‰ÎÂÊË ‰‡ ·˙‰Â ÛÚÓ˜ÌÂ̇. àÌÙÓχˆËflÚ‡ Á‡ ËÒ͇ ÓÚ ‰ÂÏÂ̈Ëfl  ÓÚ Íβ˜Ó‚Ó Á̇˜ÂÌË Á‡ Ô·ÌË‡Ì ̇ ÚÂ‡Ô‚Ú˘ÌËfl ÔÓ‰ıÓ‰ Í˙Ï ÚÂÁË ·ÓÎÌË. äÓ„ÌËÚË‚ÌËÚ ̇Û¯ÂÌËfl ÔË èÅ Ò‡ Ë̉Ë͇ÚÓ Á‡ ÎÓ¯ ÚÂ‡Ô‚Ú˘ÂÌ ÓÚ„Ó‚Ó Ë ˜ÂÒÚË ÒÚ‡Ì˘ÌË ÂÙÂÍÚË Í˙Ï ‡ÌÚËÔ‡ÍËÌÒÓÌÓ‚ËڠωË͇ÏÂÌÚË, ͇ÍÚÓ Ë Á‡ ÔÓ-ÎÓ¯‡ ‚ËÚ‡Î̇ ÔÓ„ÌÓÁ‡ ‚ Ò‡‚ÌÂÌËÂ Ò Ô‡ˆËÂÌÚËÚ ·ÂÁ ‰ÂÏÂ̈Ëfl (11). éÒ‚ÂÌ ÚÓ‚‡, ÍÓ„ÌËÚË‚ÌËÚ ̇Û¯ÂÌËfl Á‡Òfl„‡Ú ͇˜ÂcÚ‚ÓÚÓ Ì‡ ÊË‚ÓÚ (17), ‰ÓÔË̇ÒflÚ Í˙Ï ‰ËÒÚÂÒ‡ ̇ ·ÎËÁÍËÚ ̇ Ô‡ˆËÂÌÚËÚ (3) Ë ÛÒÍÓfl‚‡Ú ̇ÒÚ‡Ìfl‚‡ÌÂÚÓ Ì‡ Ô‡ˆËÂÌÚËÚ ‚ ËÌÒÚËÚÛˆËË Á‡ ‰˙΄ÓÒÓ˜ÌÓ Ó·„ËÊ‚‡Ì (4), ñÂÎÚ‡ ̇ ̇¯ÂÚÓ ÔÓÛ˜‚‡Ì  ‰‡ ÓÔ‰ÂÎËÏ ÒÔˆËÙ˘ÌËfl ÔÓÙËΠ̇ ‡ÏÌÂÒÚ˘ÌËfl ÚËÔ ÎÂÍË ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl ÔË Ô‡ˆËÂÌÚË Ò èÅ-ãäç, ͇ÚÓ Ò ӷ˙Ì ÒÔˆˇÎÌÓ ‚ÌËχÌË ̇ ÓˆÂÌ͇ڇ ̇ Ô‡ÏÂÚÚ‡ Ë ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË. 燯‡Ú‡ ıËÔÓÚÂÁ‡ Â, ˜Â Ô‡ÏÂÚÓ‚ËflÚ ‰ÂÙˈËÚ Ë ÂÍÁÂÍÛÚ˂̇ڇ ‰ËÒÙÛÌ͈Ëfl Ò‡ ÔÓÒÚÓflÌÌÓ Ô‰ÒÚ‡‚ÂÌË ÔË Ô‡ˆËÂÌÚËÚÂ Ò èÅ-ãäç, ÍÓÂÚÓ Ò ‰˙ÎÊË Ì‡È-‚˜ ̇ ÍÓÚË͇ÎÌÓ-ÒÛ·ÍÓÚË͇Î̇ ‰ËÒÙÛÌ͈Ëfl. äéçíàçÉÖçí à åÖíéÑàäÄ èÓÛ˜‚‡ÌÂÚÓ Â Ôӂ‰ÂÌÓ ‚ ÍÎËÌË͇ڇ ÔÓ Ì‚ÓÎÓ„Ëfl ̇ ìåÅÄã “ÄÎÂÍ҇̉Ó‚Ò͇” ëÓÙËfl ÔË 47 ·ÓÎÌË Ò èÅãäç Ë ÔË 25 ÍÎËÌ˘ÌÓ Á‰‡‚Ë Îˈ‡. Ñˇ„ÌÓÁ‡Ú‡  ÔÓÒÚ‡‚fl̇ ‚˙Á ÓÒÌÓ‚‡ ̇ ÔÓ‰ӷ̇ ‡Ì‡ÏÌÂÁ‡, ÒÓχÚ˘ÂÌ Ë Ì‚ÓÎӄ˘ÂÌ Ô„Ή, ··Ó‡ÚÓÌË ËÁÒΉ‚‡ÌËfl Ë ÍÓÏÔ˛Ú˙̇ ÚÓÏÓ„‡ÙËfl (ëí) ËÎË Ï‡„ÌËÚÌÓ ÂÁÓ̇ÌÒ̇ ÚÓÏÓ„‡ÙËfl (åêí) ̇ ÏÓÁ˙͇. ëÍËÌË„Ó‚ËÚ Ò͇ÎË Mini Mental State (MMS) Ë Dementia Rating Scale (DRS) Ò‡ ËÁÔÓÎÁ‚‡ÌË Á‡ ÓˆÂÌ͇ ̇ Ó·˘Ëfl ÍÓ„ÌËÚË‚ÂÌ Í‡Ô‡ˆËÚÂÚ. ÅÓÎÌËÚÂ Ò èÅ-ãäç ËÁÔ˙ÎÌfl‚‡Ú ÍËÚÂËËÚ Á‡ ‡ÏÌÂÒÚ˘ÂÌ ÚËÔ ãäç (Mayo Clinic Alzheimer’s Disease Center), Ò ËÁÍβ˜ÂÌË ̇ ÚӘ͇ 5 ‚, ÍÓflÚÓ Â ÔË·‡‚ÂÌÓ, ˜Â ÔË Ô‡ˆËÂÚËÚ ÎËÔÒ‚‡Ú ‰Û„Ë Ì‚ÓÎӄ˘ÌË Á‡·ÓÎfl‚‡ÌËfl ÓÒ‚ÂÌ èÅ. ë Ú‡ÁË ÔÓÏfl̇ ÍËÚÂËËÚ ‰Ó·Ë‚‡Ú ÒΉÌËfl ‚ˉ: 1) Ô‡ÏÂÚÓ‚Ó ÓÔ·͂‡Ì ÓÚ ÒÚ‡Ì‡ ̇ Ô‡ˆËÂÌÚ‡ ËÎË ÒË„ÛÂÌ ËÌÙÓχÚÓ; 2) ÌÓχÎÌÓ Ó·˘Ó ÍÓ„ÌËÚË‚ÌÓ ÙÛÌ͈ËÓÌË‡Ì (MMSE > 25) 3) Ó·ÂÍÚË‚ÌÓ Ô‡ÏÂÚÓ‚Ó Ì‡Û¯ÂÌËÂ, ÍÓÂÚÓ Ò ‰ÂÏÓÌÒÚË‡ Ò ÂÁÛÎÚ‡ÚË ÔÓ-„ÓÎÂÏË ÓÚ 1.5 SD ÔÓ‰ ‚˙Á‡ÒÚÓ‚Ó Ë Ó·‡ÁÓ‚‡ÚÂÎÌÓ Ò‚˙Á‡ÌË ÍÓÌÚÓÎË; 4) Ó·˘Ó Á‡Ô‡ÁÂÌ ÙÛÌ͈ËÓ̇ÎÂÌ Í‡Ô‡ˆËÚÂÚ Ë Âʉ̂̇ ‡ÍÚË‚ÌÓÒÚ Ë 5) ÎËÔÒ‡ ̇ ‰Û„Ë Ì‚ÓÎӄ˘ÌË (ÓÒ‚ÂÌ è‡ÍËÌÒÓÌÓ‚‡Ú‡ ·ÓÎÂÒÚ), ÔÒËıˇÚ˘ÌË ËÎË ÒÓχÚ˘ÌË Á‡·ÓÎfl‚‡ÌËfl, ͇ÍÚÓ Ë ÍÓÌÒÛχˆËflÚ‡ ̇ ÎÂ͇ÒÚ‚‡, ÍÓËÚÓ ·Ëı‡ ÏÓ„ÎË ‰‡ ËÌˈËË‡Ú ÍÓ„ÌËÚË‚ÌÓ ‚ÎÓ¯‡‚‡ÌÂ. чÌÌËÚ ÓÚ Ì‚ÓÔÒËıÓÎӄ˘ÌËÚ ËÁÒΉ‚‡ÌËfl ‚ „ÛÔ‡Ú‡ ·ÓÎÌË Â Ò‡‚Ìfl‚‡Ì‡ Ò ÚÂÁË Ì‡ ÍÓÌÚÓÎ̇ „ÛÔ‡ Ò˙ÒÚ‡‚Â̇ ÓÚ ‰‚‡‰ÂÒÂÚ Ë ÔÂÚ ÍÎËÌ˘ÌÓ Á‰‡‚Ë Îˈ‡, ÍÓËÚÓ ÓÚ„Ó‚‡flÚ ÔÓ ‚˙Á‡ÒÚ Ë Ó·‡ÁÓ‚‡ÚÂÎÂÌ ˆÂÌÁ ̇ Ô‡ˆËÂÌÚËÚÂ. í Ì Ò˙Ó·˘‡‚‡Ú ‰‡ÌÌË, ÌËÚÓ ËÏ‡Ú ÒËÏÔÚÓÏË Á‡ ͇͂ËÚÓ Ë ‰‡  ÔÒËıˇÚ˘ÌË ËÎË Ì‚ÓÎӄ˘ÌË Á‡·ÓÎfl‚‡ÌËfl Ë ÒÍËÌËÌ„Ó‚ÓÚÓ Ì‚ÓÔÒËıÓÎӄ˘ÌÓ ËÁÒΉ‚‡Ì Ì ÔÓ͇Á‚‡ ̇Û¯ÂÌËfl ̇ ÍÓ„ÌËÚË‚ÌËÚ ËÏ ÙÛÌ͈ËË. äÓ„ÌËÚË‚ÌËÚ ÙÛÌ͈ËË ÔË Ô‡ˆËÂÌÚËÚÂ Ë ÔË „ÛÔ‡-

78

Ú‡ ÓÚ Á‰‡‚Ë ÍÓÌÚÓÎË Ò‡ ËÁÒΉ‚‡ÌË Ò ÔÓ‰ӷ̇ Ì‚ÓÔÒËıÓÎӄ˘̇ ·‡ÚÂËfl, Ò˙ÒÚ‡‚Â̇ ÓÚ ÚÂÒÚÓ‚Â Ë Ò˙Í‡ÚÂÌË ‚ÂÒËË Ì‡ ¯ËÓÍÓ ËÁÔÓÎÁ‚‡ÌË Ì‚ÓÔÒËıÓÎӄ˘ÌË ÏÂÚÓ‰ËÍË. è‡ÏÂÚÚ‡  ËÁÒΉ‚‡Ì‡ Ò: Digit Span (forward) Á‡ ÓˆÂÌ͇ ̇ Í‡ÚÍÓÒӘ̇ ‚Â·‡Î̇ Ô‡ÏÂÚ, ͇ÍÚÓ Ë Ò Buschke Free and Cued Selective Reminding Test (FCSRT) Á‡ ÓˆÂÌ͇ ̇ ‚Â·‡Î̇ ÂÔËÁӉ˘̇ Ô‡ÏÂÚ ˜ÂÁ ËÁÒΉ‚‡Ì ̇ Ò‚Ó·Ó‰ÌÓÚÓ ÔËÔÓÏÌflÌÂ, Ó·˘ÓÚÓ (Ò‚Ó·Ó‰ÌÓ Ë ÛÎÂÒÌÂÌÓ) ÔËÔÓÏÌflÌÂ Ë ‡ÁÔÓÁ̇‚‡ÌÂÚÓ. ÇÌËχÌËÂÚÓ Ë ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË Ò‡ ËÁÒΉ‚‡ÌË Ò: Trail Making Test – Ä (TMT-A) Ë Ç (TMT-B); Modified Card Sorting Test (MCST); ÇÂ·‡Î̇ ÙÎÛˉÌÓÒÚ (ÙÓÌÂÏ̇), Ë Stroop Test. ê˜ڇ  ËÁÒΉ‚‡Ì‡ Ò Í‡Ú͇ ‚ÂÒËfl ̇ Boston Naming Test (BNT) Ë Ò ÇÂ·‡Î̇ ÙÎÛˉÌÓÒÚ (͇Ú„ÓˇÎ̇). äÓÌÒÚÛÍÚË‚ÌËfl Ô‡ÍÒËÒ Â ËÁÒΉ‚‡Ì ˜ÂÁ ÔÓ‰Ò͇·ڇ ̇ Dementia Rating Scale (DRS). ï‡‡ÍÚÂËÒÚËÍËÚ ̇ ‚Íβ˜ÂÌËÚ „ÛÔË Ò‡ Ô‰ÒÚ‡‚ÂÌË Ì‡ Ú‡·Îˈ‡ 1. ê‡ÁÎËÍËÚ ÏÂÊ‰Û ‰‚ÂÚ „ÛÔË ‚‚˙‚ ‚˙Á‡ÒÚÚ‡, Ó·‡ÁÓ‚‡ÌËÂÚÓ, ÂÁÛÎÚ‡ÚËÚ ÓÚ MMS, DRS Ë Ì‚ÓÔÒËıÓÎӄ˘ÌËÚ ÚÂÒÚÓ‚Â Ò‡ ÓˆÂÌfl‚‡ÌË Ò ÔÓÏÓ˘Ú‡ ̇ non paired t-test. 퇷Îˈ‡ 1: ï‡‡ÍÚÂËÒÚËÍË Ì‡ ‚Íβ˜ÂÌËÚ „ÛÔË äÓÌÚÓÎË (n=25) èÅ-ãäç (n=47) Ç˙Á‡ÒÚ 73.3 (7.0) 71.2 (7.7) é·‡ÁÓ‚‡ÌË 12.8 (3.4) 12.0 (4.0) MMSE 29.0 (0.0) 26.6 (1.4) DRS 141.9 (1.6) 134.1 (5.1) чÌÌËÚ ҇ Ò‰ÌË ‡ËÚÏÂÚ˘ÌË (SD); MMS = Mini Mental State; DRS = Dementia Rating Scale èË Ò‡‚Ìfl‚‡Ì ̇ ·‡ÁËÒÌËÚ ı‡‡ÍÚÂËÒÚËÍË Ì‡ ‰‚ÂÚ „ÛÔË ÔÓ ÓÚÌÓ¯ÂÌË ̇ ‚˙Á‡ÒÚ, Ó·‡ÁÓ‚‡ÌËÂ Ë Ó·˘Ó ÍÓ„ÌËÚË‚ÌÓ ÙÛÌ͈ËÓÌË‡Ì Ì Ò ̇·Î˛‰‡‚‡ ÒÚ‡ÚËÒÚ˘ÂÒÍË Á̇˜Ëχ ‡ÁÎË͇ ÏÂÊ‰Û Úflı. èË ‚Ò ÚÓ‚‡ Ô‡ˆËÂÌÚËÚÂ Ò èÅ-ãäç ÔÓ͇Á‚‡Ú ÚẨÂ̈Ëfl Á‡ ÔÓ-ÌËÒÍË ÂÁÛÎÚ‡ÚË ÔË ÚÂÒÚÓ‚ÂÚ Á‡ Ó·˘Ó ÍÓ„ÌËÚË‚ÌÓ ÙÛÌ͈ËÓÌË‡ÌÂ. êÖáìãíÄíà êÂÁÛÎÚ‡ÚËÚ ÓÚ Ì‚ÓÔÒËıÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡Ì ÔË ·ÓÎÌËÚÂ Ò èÅ-ãäç Ë ÔË Á‰‡‚ËÚ ÍÓÌÚÓÎË Ò‡ Ô‰ÒÚ‡‚ÂÌË Ò˙ÓÚ‚ÂÚÌÓ Ì‡ Ú‡·ÎËˆË 2 Ë 3.

îË„Û‡ 1: êÂÁÛÎÚ‡ÚË ÓÚ ËÁÔ˙ÎÌÂÌËÂÚÓ Ì‡ FCSRT (Free and Cued Selective Reminding Test) ÔË Ô‡ˆËÂÌÚË Ò è‡ÍËÌÒÓÌÓ‚‡ ·ÓÎÂÒÚ Ë ÎÂÍÓ ÍÓ„ÌËÚË‚ÌÓ Ì‡Û¯ÂÌË (èÅãäç) ‚ Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎ̇ „ÛÔ‡: ë‚è = Ò‚Ó·Ó‰ÌÓ ÔËÔÓÏÌflÌÂ, é·è= Ó·˘Ó ÔËÔÓÏÌflÌ ( Ò‚Ó·Ó‰ÌÓ Ë ÛÎÂÒÌÂÌÓ), ë‚éÚ‰ = Ò‚Ó·Ó‰ÌÓ ÓÚ‰‡Î˜ÂÌÓ ÔËÔÓÏÌflÌÂ, é·éÚ‰ = Ó·˘Ó ÓÚ‰‡Î˜ÂÌÓ ÔËÔÓÏflÌÂ, ê‡Á = ‡ÁÔÓÁ̇‚‡ÌÂ


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

èË ÚÂÒÚ‡ Á‡ ‚Â·‡Î̇ ÂÔËÁӉ˘̇ Ô‡ÏÂÚ Ô‡‚Ë ‚Ô˜ÂÚÎÂÌËÂ, ˜Â Ô‡ˆËÂÌÚËÚÂ Ò èÅ-ãäç ÔÓ͇Á‚‡Ú Á̇˜ËÏÓ Ì‡Û¯ÂÌË Ì ҇ÏÓ ‚ Ó·˘ÓÚÓ ÔËÔÓÏÌflÌÂ, ÌÓ Ò˙˘Ó ڇ͇ Ë ‚ Ò‚Ó·Ó‰ÌÓÚÓ ÌÂÔÓÒ‰ÒÚ‚ÂÌÓ Ë ÓÚ‰‡Î˜ÂÌÓ ÔËÔÓÏflÌ ̇ FCSRT ‚ Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎ̇ڇ „ÛÔ‡. ìÎÂÒÌÂÌÓÚÓ ÔËÔÓÏÌflÌ Á̇˜ËÏÓ ÔÓ‰Ó·fl‚‡ Ó·˘ÓÚÓ ÔËÔÓÏÌflÌÂ. èË ‡ÁÔÓÁ̇‚‡ÌÂÚÓ Ì Ò ÛÒÚ‡ÌÓ‚fl‚‡ Á̇˜Ëχ ‡ÁÎË͇ ÏÂÊ‰Û ‰‚ÂÚ „ÛÔË. 퇷Îˈ‡ 2: êÂÁÛÎÚ‡ÚË ÓÚ ÚÂÒÚÓ‚Â Á‡ ‚ÌËχÌËÂ Ë ÂÍÁÂÍÛÚË‚ÌË ÙÛÌ͈ËË íÂÒÚÓ‚Â äÓÌÚÓÎË èÅ-ãäç p< TMT A (t) 59.8 (14.6) 94.2 (32.5) 0.0004 TMT B (t) 139.8 (35.3) 258.2 (85.7) <0.0001 TMT B-A 73.9 (36.9) 164.0 (88.2) 0.0004 Stroop Test 34.3 (7.1) 25.4 (8.7) 0.015 Digit span (B) 4.4 (0.5) 3.5 (1.0) 0.02 ãËÚÂ‡Î̇ ÙÎÛˉÌÓÒÚ (ÙÓÌÂÏ̇) 12.9 (4.5) 7.6 (3.4) 0.002 MCST 5.62 (0.7) 4.6 (1.5) 0.07 чÌÌËÚ ҇ Ò‰ÌË ‡ËÚÏÂÚ˘ÌË (SD). (t-test p < 0.05) MCST = Modified Card Sorting Test 퇷Îˈ‡ 3: êÂÁÛÎÚ‡ÚË ÓÚ ÚÂÒÚÓ‚ÂÚ Á‡ Í‡ÚÍÓÒӘ̇ Ô‡ÏÂÚ, ˜ Ë ÍÓÌÒÚÛÍÚË‚ÂÌ Ô‡ÍÒËÒ äÓÌÚÓÎË èÅ-ãäç p< Boston Naming Test 14.9 (0.3) 14.5 (0.9) 0.26 ÇÂ·‡Î̇ ÙÎÛˉÌÓÒÚ (͇Ú„ÓˇÎ̇) 22.0 (4.8) 17.0(4.8) 0.02 Digit Span (F) 5.7 (1.2) 5.2 (1.0) 0.17 äÓÌÒÚÛË‡Ì 5.9 (0.3) 5.8 (0.4) 0.64 чÌÌËÚ ҇ Ò‰ÌË ‡ËÚÏÂÚ˘ÌË (SD). (t-test p < 0.05) BNT = Boston Naming test èÓ ÓÚÌÓ¯ÂÌË ̇ ÚÂÒÚÓ‚ÂÚÂ, ÍÓËÚÓ ËÁÒΉ‚‡Ú ‡Á΢ÌË ‡ÒÔÂÍÚË Ì‡ ‚ÌËχÌËÂÚÓ Ë ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË Ò ÛÒÚ‡ÌÓ‚fl‚‡ ÒÚ‡ÚËÒÚ˘ÂÒÍË Á̇˜Ëχ ‡ÁÎË͇ ÔË íåí Ä Ë Ç, Stroop ÚÂÒÚ, digit span Ë ‚Â·‡Î̇ ÙÎÛˉÌÓÒÚ (å), ͇ÍÚÓ Ë ‚ ÔÒËıÓÏÓÚÓ̇ڇ ÒÍÓÓÒÚ, ÍÓflÚÓ Ò ÓÚ˜ËÚ‡ ˜ÂÁ ‡ÁÎË͇ڇ ‚˙‚ ‚ÂÏÂÚÓ, ÌÂÓ·ıÓ‰ËÏÓ Á‡ ËÁÔ˙ÎÌÂÌË ̇ íåí-Ç Ë íåí-Ä. èÓ ÓÚÌÓ¯ÂÌË ̇ ÚÂÒÚÓ‚ÂÚ ӈÂÌfl‚‡˘Ë Í‡ÚÍÓÒӘ̇ڇ Ô‡ÏÂÚ Ë ˜‚ËÚ ÒÔÓÒÓ·ÌÓÒÚË Ò ÛÒÚ‡ÌÓ‚fl‚‡ Á̇˜ËÏÓÒÚ Ò‡ÏÓ ÔË ÚÂÒÚ‡ Á‡ ‚Â·‡Î̇ ÙÎÛˉÌÓÒÚ (ÊË‚ÓÚÌË). ᇉ‡˜‡Ú‡, ÓˆÂÌfl‚‡˘‡ ÍÓÌÒÚÛÍÚË‚ÌËfl Ô‡ÍÒËÒ, Ò˙˘Ó Ì ÔÓ͇Á‚‡ ‡Á΢Ëfl ÏÂÊ‰Û ‰‚ÂÚ ËÁÒΉ‚‡ÌË „ÛÔË. éÅëöÜÑÄçÖ éÒÌÓ‚ÌËÚ ‰‡ÌÌË ÓÚ Ôӂ‰ÂÌÓÚÓ ÔÓÛ˜‚‡Ì ÒÓ˜‡Ú, ˜Â ËÁÒΉ‚‡ÌËÚ ÓÚ Ì‡Ò Ô‡ˆËÂÌÚË Ò èÅ-ãäç ‰ÂÏÓÌÒÚË‡Ú Ì‚ÓÔÒËıÓÎӄ˘ÂÌ ÔÓÙËÎ, ÍÓÈÚÓ Ò˙˜ÂÚ‡‚‡ ͇ÍÚÓ Ô‡ÏÂÚÓ‚Ë Ì‡Û¯ÂÌËfl, ڇ͇ Ë Ì‡Û¯ÂÌË ‚ ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË. Ç Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎËÚ ̇¯ËÚ ԇˆËÂÌÚË Ò èÅ-ãäç ÔÓ͇Á‚‡Ú Á̇˜ËÏ ‰ÂÙˈËÚ ‚ ÌÂÔÓÒ‰ÒÚ‚ÂÌÓÚÓ Ë ÓÚ‰‡Î˜ÂÌÓ ÔËÔÓÏÌflÌ ÔË FCSRT, ‚Â·‡Î̇ڇ ÙÎÛˉÌÓÒÚ (ÙÓÌÂÏ̇ Ë Í‡Ú„ÓˇÎ̇), ÔÒËıÓÏÓÚÓ̇ڇ ÒÍÓÓÒÚ Ë ÍÓ„ÌËÚ˂̇ڇ ÔÓÒΉӂ‡ÚÂÎÌÓÒÚ/ÙÎÂÍÒË·ËÎÌÓÒÚ ÔË íåí, ËÌıË·Ë‡Ì ̇ ̇‰ÂÍ‚‡ÚÌËÚ Á‡ ÒÎÛ˜‡fl, ‡ÁÒÂÈ‚‡˘Ë ¯ÂÌËfl ÔË Stroop test Ë ‚ ‡·ÓÚ̇ڇ Ô‡ÏÂÚ ËÁÒΉ‚‡Ì‡ ˜ÂÁ Digit Span backwards. åÓ‰ÂÎ˙Ú Ì‡ Ô‡ÏÂÚÓ‚ËÚ ̇Û¯ÂÌËfl ÔË ÚÂÁË Ô‡ˆËÂÌÚË Ò ı‡‡ÍÚÂËÁË‡ Ò ÔÓ‰Ó·ÂÌÓ ÔËÔÓÏflÌ ˜ÂÁ Íβ˜Ó‚Ë ‰ÛÏË Ë ÌÓχÎÌÓ ‡ÁÔÓÁ̇‚‡ÌÂ, ‰‡ÌÌË ÚËÔ˘ÌÓ Ì‡·Î˛‰‡‚‡ÌË ÔË Ô‡ˆËÂÌÚË Ò ÙÓÌÚÓ-ÒÚˇڇÎ̇ ‰ËÒÙÛÌ͈Ëfl, ÍÓËÚÓ ÔÓ‰Ó·fl‚‡Ú ËÁÔ˙ÎÌÂÌËÂÚÓ ÒË ˜ÂÁ ÔÓ‰ÔÓχ„‡ÌÂ.

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çË ÛÒÚ‡ÌÓ‚fl‚‡Ï Ò˙˘Ó ڇ͇, ˜Â ÔË Ì‡ÁÓ‚‡‚‡ÌÂÚÓ Ë Ô‡ÏÂÚÓ‚Ëfl Ó·ı‚‡Ú, ÍÓ„ÌËÚË‚ÌË ÙÛÌ͈ËË, ÍÓËÚÓ Ò‡ Ò ÓÚÌÓÒËÚÂÎÌÓ ÌËÒ˙Í ÂÍÁÂÍÛÚË‚ÂÌ ÚÓ‚‡, ÂÁÛÎÚ‡ÚËÚ ̇ Ô‡ˆËÂÌÚËÚÂ Ò èÅ-ãäç Ò‡ ‚ ÌÓχÎÌË „‡ÌˈË. éÚ ‰Û„‡ ÒÚ‡Ì‡, ÔË ÂÁËÍÓ‚ËÚ ÙÛÌ͈ËË, ÍÓËÚÓ Ò‡ Ò‚˙Á‡ÌË Ò˙Ò Á̇˜ËÏÓ ‚˙‚΢‡Ì ̇ ÂÍÁÂÍÛÚË‚ÌËÚ ÍÓÏÔÓÌÂÌÚË, ͇ÍÚÓ Â ÔË ‚Â·‡Î̇ ÙÎÛˉÌÓÒÚ (ÊË‚ÓÚÌË), Ô‡ˆËÂÌÚËÚ ÔÓ͇Á‚‡Ú Á̇˜ËÏ ‰ÂÙˈËÚ. ífl·‚‡ ‰‡ Ò ÓÚ·ÂÎÂÊË Ò˙˘Ó ڇ͇, ˜Â ËÁÒΉ‚‡ÌËÚ ÂÍÁÂÍÛÚË‚ÌË ÙÛÌ͈ËË ÔË Ì‡¯ËÚ ԇˆËÂÌÚË Ò‡ ÒÂÎÂÍÚË‚ÌÓ Ì‡Û¯ÂÌË. ÖÍÁÂÍÛÚË‚ÌËÚ ÒÛ·ÍÓÏÔÓÌÂÌÚË ÔË ËÁÒΉ‚‡ÌËÚ ÓÚ Ì‡Ò Ô‡ˆËÂÌÚË Ò èÅ-ãäç, ÍÓËÚÓ Ò‡ ̇ÈÁ‡Ò„̇ÚË, Ò‡ ËÌˈˇˆËflÚ‡ Ë ÒÚ‡Ú„˘ÂÒÍÓÚÓ Ú˙ÒÂÌÂ, ÍÓ„ÌËÚ˂̇ڇ ÙÎÂÍÒË·ËÎÌÓÒÚ Ë ËÌıË·ËÚÓÌËfl ÍÓÌÚÓÎ. ç‡Û¯ÂÌÓÚÓ ÙÛÌ͈ËÓÌË‡Ì Ò ‰ÂÏÓÌÒÚË‡ flÒÌÓ ÔË Ôӈ‰ÛË, Ò‚˙Á‡ÌË Ò ‚ÂÏÂ‚Ó ÚÂÒÚÛ‚‡ÌÂ. ᇠ‡ÁÎË͇ ÓÚ ÓÒڇ̇ÎËÚ ÒÛ·ÍÓÏÔÓÌÂÌÚË Ì‡ ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË, ÍÓ̈ÂÔÚÛ‡ÎËÁ‡ˆËflÚ‡ Ì ÔÓ͇Á‚‡ Á̇˜ËÏË Ì‡Û¯ÂÌËfl. èÓ‰Ó·ÌË ÂÁÛÎÚ‡ÚË Ò‡ Ò˙Ó·˘ÂÌË Ì‡ÒÍÓÓ ‚ ‰‚ ÔÓÛ˜‚‡ÌËfl, ÍÓËÚÓ ÛÒÚ‡ÌÓ‚fl‚‡Ú, ˜Â ÂÍÁÂÍÛÚË‚ÌËÚ ‰ËÒÙÛÌ͈ËË ÔË Ô‡ˆËÂÌÚË Ò èÅ-ãäç ËÏ‡Ú „ÓÎflχ ÔÓ„ÌÓÒÚ˘̇ ÒÚÓÈÌÓÒÚ Á‡ ÔÓ-̇ڇڇ¯ÌÓ ‡Á‚ËÚË ̇ ‰ÂÏÂ̈Ëfl (9,10). êÂÁÛÎÚ‡ÚËÚ ÓÚ Ôӂ‰ÂÌÓ ÓÚ Ì‡Ò ÔÓÛ˜‚‡Ì ‚˙ıÛ èÅ-ãäç Ò˙ÓÚ‚ÂÚÒÚ‚‡Ú Ë Ì‡ ÂÁÛÎÚ‡ÚËÚÂ, ÔÓÎÛ˜ÂÌË ÔË Ô‡ˆËÂÌÚË ‚ ÏÌÓ„Ó ‡ÌÂÌ ÒÚ‡‰ËÈ Ì‡ ÅÄ, ÔË ÍÓËÚÓ Ò ÛÒÚ‡ÌÓ‚fl‚‡, ˜Â ̇Û¯ÂÌËflÚ‡ ‚ ÒÙÂËÚ ̇ ÂÔËÁӉ˘̇ڇ Ô‡ÏÂÚ Ë ÂÍÁÂÍÛÚË‚ÌËÚ ÙÛÌ͈ËË Ô‰¯ÂÒÚ‚‡Ú ̇Û¯ÂÌËflÚ‡ ‚ ÍÓÌÒÚÛÍÚË‚ÌËfl Ô‡ÍÒËÒ, ˜ڇ Ë ÔÓ‰‰˙ʇÌÂÚÓ Ì‡ ‚ÌËχÌËÂÚÓ (5). ëÂÎÂÍÚË‚ÌËflÚ ÂÍÁÂÍÛÚË‚ÂÌ ‰ÂÙˈËÚ Â ˜ÂÒÚÓ Ô˙‚Ëfl, ÍÓÈÚÓ Ò ̇·Î˛‰‡‚‡ ÔË Ô‡ˆËÂÌÚË Ò èÅ (18). è‰ÔÓ·„‡ ÒÂ, ˜Â ̇Û¯ÂÌËflÚ‡ ‚ ÚÂÁË ÙÛÌ͈ËË Ò‡ Ò‚˙Á‡ÌË Ò Ì‡Ï‡ÎÂ̇ڇ ‡ÍÚË‚ÌÓÒÚ ‚ ӷ·ÒÚÚ‡ ̇ ·‡Á‡ÎÌËÚ „‡Ì„ÎËË Ë ÙÓÌÚ‡ÎÌËfl ÍÓÚÂÍÒ (12). Ç Á‡Íβ˜ÂÌË ÂÁÛÎÚ‡ÚËÚ ÓÚ Ì‡¯ÂÚÓ ÔÓÛ˜‚‡Ì ̇ÒÓ˜‚‡Ú Í˙Ï ÌÂÓ·ıÓ‰ËÏÓÒÚÚ‡ ÓÚ ÏÌÓ„Ó ÔÓ-ÍÓÏÔÎÂÍÒÌÓ ÍÓ„ÌËÚË‚ÌÓ ËÁÒΉ‚‡ÌÂ, ÙÓÍÛÒË‡ÌÓ ‚˙ıÛ ÂÍÁÂÍÛÚË‚ÌËÚÂ Ë Ô‡ÏÂÚÓ‚ËÚ ÔÓˆÂÒË Á‡ ‡ÌÌÓ ÓÚÍË‚‡Ì ̇ ÎÂÍËÚ ÍÓ„ÌËÚË‚ÌË Ì‡Û¯ÂÌËfl ÔË èÅ. çÂÓ·ıÓ‰ËÏË Ò‡ Ë Ôӂ˜ ÔÓÒÔÂÍÚË‚ÌË ÔÓÛ˜‚‡ÌËfl, Á‡ ‰‡ Ò ËÁflÒÌË ÎÓÌ„ËÚÓ‰Ë̇ÎÌËfl ıÓ‰ ̇ ‡ÌÌËÚ ÍÓ„ÌËÚË‚ÌË ÔÓÏÂÌË ÔË èÅ Ë ‰‡ Ò ÓÔ‰ÂÎË, ÍÓË ÓÚ Úflı Ô‰ÒÚ‡‚Îfl‚‡Ú Ô‰¯ÂÒÚ‚ÂÌËÍ Ì‡ ‰ÂÏÂ̈Ëfl. ãàíÖêÄíìêÄ 1. Aarsland, D., Andersen, K., Larsen, J.P., Lolk, A., Nielsen, H., Kragh-Sorensen, P. Risk of dementia in Parkinson’s disease: a community-based, prospective study. Neurology, 56, 2001, 6, 730-6. 2. Aarsland, D., Andersen, K., Larsen, J.P., Lolk, A., Kragh-Sorensen, P. Prevalence and characteristics of dementia in Parkinson disease: an 8-year prospective study. Arch Neurol, 60, 2003, 387-392. 3. Aarsland, D., Larsen, J.P., Karlsen, K., Lim, N.G., Tandberg, E. Mental symptoms in Parkinson's disease are important contributors to caregiver distress. Int J Geriatr Psychiatry 14, 1999, 866-874. 4. Aarsland, D., Larsen, J.P., Tandberg, E.,, Laake, K. Predictors of nursing home placement in Parkinson's disease: a population-based, prospective study. J Am Geriatr Soc. 48, 2000, 8, 938-42. 5. Baudic, S., Barba, G.D., Thibaudet, M.C., Smagghe, A., Remy, P., Traykov, L. Executive function deficits in early Alzheimer's disease and their relations with episodic memory Arch Clin Neuropsychol. 2006 in press 6. Foltynie, T., Brayne, C.E., Robbins, T.W., Barker, R.A. The cognitive ability of an incident cohort of Parkinson's patients in the UK. The CamPaIGN study. Brain, 127, 2004, 3, 550-560. 7. Green, J., McDonald, W.M., Vitek, J.L., Evatt, M., Freeman, A., Haber, M., Bakay, R.A., Triche, S., Sirockman, B., DeLong, M.R. Cognitive impairments in advanced PD without dementia. Neurology, 59, 2002, 1320-4 8. Hughes, T.A., Ross, H.F., Musa, S., Bhattacherjee, S., Nathan, R.N., Mindham, R.H., Spokes, E.G. A 10-year study of the incidence of and factors predicting dementia in Parkinson’s disease. Neurology, 54, 2000, 1596-602 9. Janvin, C.C., Larsen, J.P., Aarsland, D., Hugdahl, K. Subtypes of mild cognitive impairment in Parkinson's disease: progression to dementia. Mov Disord. 21, 2006, 1343-9. 10. Levy, G., Jacobs, D.M., Tang, M.X., Cote, L.J., Louis, E.D., Alfaro, B., Mejia, H., Stern, Y., Marder, K. Memory and executive function impairment predict dementia in Parkinson's disease. Mov Disord, 17, 2002, 1221-6. 11. Levy, G., Tang, M.X., Louis, E.D., Cote, L.J., Alfaro, B., Mejia, H., Stern, Y., Marder, K. The association of incident dementia with mortality in PD. Neurology,


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

59, 2002, 1708-13. 12. Lewis, S.J., Dove, A., Robbins, T.W., Barker, R.A., Owen, A.M. Cognitive impairments in early Parkinson's disease are accompanied by reductions in activity in frontostriatal neural circuitry J Neurosci, 23, 2003, 6351-6. 13. Muslimovic, D., Post, B., Speelman, J.D., Schmand, B. Cognitive profile of patients with newly diagnosed Parkinson disease Neurology, 65, 2005, 1239-45. 14. Petersen, R.C., Doody, R., Kurz, A., et al. Current concepts in mild cognitive impairment. Arch Neurol, 58, 2001, 1985-1992. 15. Petersen, R.C., Stevens, J.C., Ganguli, M., Tangalos, E.G., Cummings, J.L., DeKosky, S.T. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 56, 2001, 1133-1142 16. Ritchie, K., Artero, S., Touchon, J. Classification criteria for mild cognitive impairment: a population-based validation study. Neurology, 56, 2001, 37–42. 17. Schrag, A., Jahanshahi, M., Quinn, N. What contributes to quality of life in patients with Parkinson's disease? J Neurol Neurosurg Psychiatry, 69, 2000, 308-

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12. 18. Woods, S.P., Troster, A.I. Prodromal frontal/executive dysfunction predicts incident dementia in Parkinson's disease. J Int Neuropsychol Soc, 9, 2003, 17-24.

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: Ñ- å. èÂÚÓ‚‡, ìåÅÄã “ÄÎÂÍ҇̉Ó‚Ò͇”, äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl, ·ÛÎ. “ÉÂÓ„Ë ëÓÙËÈÒÍË” 1, ëÓÙËfl 1431 ÚÂÎ: 02/92 30 350 Â-mail: dr.mpetrova@mail.bg

éË„Ë̇ÎÌË ÒÚ‡ÚËË åàçàåÄãçÄ óÖêçéÑêéÅçÄ ÖçñÖîÄãéèÄíàü èêà èÄñàÖçíà ë óÖêçéÑêéÅçÄ ñàêéáÄ è. Äڇ̇ÒÓ‚‡1, ç. ä¸ÒÚ‚2, ê. å‡Ò‡Î‰ÊË‚‡3, ä. Ňı˜Â‚‡ÌÓ‚4, Ä. åËı‡ÈÎÓ‚‡4, É. åÛÁË͇‰ÊË‚‡4, ï. è‡ÛÌÓ‚‡4, å. äÓÒÚ‡‰ËÌÓ‚‡4, Ñ. ÉÂÓ„Ë‚4 1äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl, åì – èÎÓ‚‰Ë‚ 2äÎËÌË͇ ÔÓ „‡ÒÚÓÂÌÚÂÓÎÓ„Ëfl, åì - èÎÓ‚‰Ë‚ 3äÎËÌË͇ ÔÓ ÔÒËıˇÚËfl Ë Ï‰ˈËÌÒ͇ ÔÒËıÓÎÓ„Ëfl, åì-èÎÓ‚‰Ë‚ 4ëÚÛ‰ÂÌÚÒÍË Ì‡Û˜ÂÌ Í˙ÊÓÍ ÔÓ Ì‚ÓÎÓ„Ëfl, åì - èÎÓ‚‰Ë‚ SUMMARY MINIMAL HEPATIC ENCEPHALOPATHY IN PATIENTS WITH LIVER CIRRHOSIS P. Atanassova, N. Krustev, R. Massaldjieva, K. Bahchevanov, A. Michajlova, G. Muzikadjieva, H. Paunova, M. Kostadinova, D. Georgiev Hepatic encephalopathy (HE) is a frequent complication of cirrhosis and its appearance indicates poor prognosis. Whereas detection of overt HE is made clinically and does not represent a major diagnostic challenge, diagnosis of minimal hepatic encephalopathy (MHE) is problematic. Psychometric and electrophysiological tests are currently used for detection of MHE. A total of 41 patients with non-alcohol-induced and alcohol-induced cirrhosis who were admitted from October 2005 until October 2006 to the Department of Gastroenterology of Medical University, Plovdiv, were studied. The severity of cirrhosis was assessed as follows: Child-Pugh A (n=21) and Child-Pugh B (n=20). We performed standard neurological examination and psychometric assessment (MMSE, Digit span forward, Digit span backward). Visual discrimination ability was assessed by determination of critical flicker frequency (CFF) thresholds. We found fine neurological symptoms in 17% of patients. Correlation analysis of the scores from the psychometric testing showed, that there is not significant relationships between results from MMSE and mean flicker r=0.003, p=0.98; as well as the scores from Digit span (DS) and mean flicker – (DS forward r=0.19, p=0.24; DS backward r=0.26, p=0.11). Seven patients meet the criteria for MHE. CFF is remarkably sensitive and objective parameter for quantification of low-grade HE severity. Combination of two major criteria for MHE: fine motor deficit together with electrophysiological abnormalities (visual discrimination ability impairments) is rarer than the more frequent cognitive impairments in patients with low-grade hepatic cirrhosis. Both processes are not parallel and simultaneous and they do not prove a synchronous validity in the early stages of HE – MHE.

KEY WORDS: minimal hepatic encephalopathy, hepatic cirrhosis, critical flicker frequency, cognitive impairment. êÖáûåÖ óÂÌÓ‰ӷ̇ڇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl (óÖ)  ˜ÂÒÚÓ ÛÒÎÓÊÌÂÌË ̇ ˆËÓÁ‡Ú‡ Ë ÔÓfl‚‡Ú‡ È ÒÓ˜Ë ÎÓ¯‡ ÔÓ„ÌÓÁ‡. ÑÓ͇ÚÓ ÓÚ˜ËÚ‡ÌÂÚÓ Ì‡ fl‚̇ڇ óÖ Â ÍÎËÌ˘ÌÓ Ë Ì Ô‰ÒÚ‡‚Îfl‚‡ „ÓÎflÏÓ ‰Ë‡„ÌÓÒÚ˘ÌÓ Ô‰ËÁ‚Ë͇ÚÂÎÒÚ‚Ó, ÚÓ ‰Ë‡„ÌÓÒÚˈË‡ÌÂÚÓ Ì‡ ÏËÌËχÎ̇ڇ ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl (åóÖ)  ÔÓ·ÎÂχÚ˘ÌÓ. èÓ̇ÒÚÓfl˘ÂÏ Á‡ ÓÚ˜ËÚ‡ÌÂÚÓ È Ò ËÁÔÓÎÁ‚‡Ú ÔÒËıÓÏÂÚ˘ÌË Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ÚÂÒÚÓ‚Â. ᇠÔÂËÓ‰‡ ÓÚ ÓÍÚÓÏ‚Ë 2005 „. ‰Ó ÓÍÚÓÏ‚Ë 2006 „. ‚ äÎËÌË͇ڇ ÔÓ „‡ÒÚÓÂÌÚÂÓÎÓ„Ëfl ̇ å‰ˈËÌÒÍË ìÌË‚ÂÒËÚÂÚ, èÎÓ‚‰Ë‚, Ò‡ ËÁÒΉ‚‡ÌË 41 Ô‡ˆËÂÌÚ‡ Ò Ì‡ÎÍÓıÓÎ̇ Ë ‡ÎÍÓıÓÎ̇ ˆËÓÁ‡. íÂÊÂÒÚÚ‡ ̇ ˆËÓÁ‡Ú‡ Ò ӈÂÌË Í‡ÚÓ Child-Pugh A ÔË 21 Ô‡ˆËÂÌÚË Ë Í‡ÚÓ Child-Pugh B ÔË 20 Ô‡ˆËÂÌÚË. èӂ‰ Ò Òڇ̉‡ÚÌÓ Ì‚ÓÎӄ˘ÌÓ ËÁÒΉ‚‡ÌÂ Ë ÔÒËıÓÏÂÚ˘ÌÓ ËÁÒΉ‚‡Ì (MMSE, Digit span forward, Digit span backward). áËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ Ò ӈÂÌË ˜ÂÁ ÓÔ‰ÂÎflÌ ̇ Ô‡„Ó‚ÂÚ ̇ ÍËÚ˘̇ڇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (äóí). éÚ˜ÂÚÓı‡ Ò ‰ËÒÍÂÚÌË Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË ÔË 17% ÓÚ Ô‡ˆËÂÌÚËÚÂ. èÓÎÛ˜ÂÌËÚ ÂÁÛÎÚ‡ÚË ÓÚ ÍÓ·ˆËÓÌÂÌ ‡Ì‡ÎËÁ ̇ ·‡ÎÓ‚ÂÚ ÓÚ ÚËÚ ÏÂÚÓ‰ËÍË ÔÓ͇Á‚‡Ú, ˜Â ÎËÔÒ‚‡ ‚˙Á͇ ÏÂÊ‰Û MMSE Ë Ò‰̇ڇ äóí r=0.003, p=0,98; ͇ÍÚÓ Ë ÏÂÊ‰Û ·‡ÎÓ‚ÂÚ ÓÚ Digit span (DS) Ë Ò‰̇ڇ äóí - DS ‚ Ô‡‚ ‰ r=0.19, p=0.24; DS ‚ Ó·‡ÚÂÌ ‰ r=0.26, p=0.11. Ñˇ„ÌÓÒÚ˘ÌËÚ ÍËÚÂËË Á‡ åóÖ Ò ËÁÔ˙ÎÌËı‡ ÔË 7 Ô‡ˆËÂÌÚË. äóí  ˜Û‚ÒÚ‚ËÚÂÎÂÌ Ë Ó·ÂÍÚË‚ÂÌ Ô‡‡Ï‡Ú˙ Á‡ Í·ÒËÙˈË‡Ì ̇ ÚÂÊÂÒÚÚ‡ ̇ ÌËÒÍÓÒÚÂÔÂÌ̇ڇ óÖ. ë˙˜ÂÚ‡ÌËÂÚÓ Ì‡ ‰‚‡ ÓÚ ÓÒÌÓ‚ÌËÚ ÍËÚÂËË Á‡ åóÖ: ‰ËÒÍÂÚÂÌ ‰‚Ë„‡ÚÂÎÂÌ ‰ÂÙˈËÚ Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ‡·ÌÓÏÌÓÒÚË (̇Û¯ÂÌËfl ‚ ÁËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ)  ÔÓ-fl‰Í‡ ̇ıӉ͇ ÔË Ô‡ˆËÂÌÚËÚÂ Ò ÎÂÍÓÒÚÂÔÂÌ̇ ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡ ‚ Ò‡‚ÌÂÌËÂ Ò ÔÓ-˜ÂÒÚËÚ ̇Û¯ÂÌËfl ̇ ÍÓ„ÌËÚË‚ÌÓÚÓ ÙÛÌ͈ËÓÌË‡ÌÂ. èÓˆÂ-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÒËÚ Ì ҇ Ô‡‡ÎÂÎÌË Ë Â‰ÌÓ‚ÂÏÂÌÌË Ë Ì ӷÂÍÚË‚ËÁË‡Ú ÒËÌıÓÌ̇ ‚‡ÎˉÌÓÒÚ ‚ ̇˜‡ÎÌËÚ ÂÚ‡ÔË ÓÚ ‡Á‚ËÚË ̇ óÖ - åóÖ. äãûóéÇà Ñìåà: ÏËÌËχÎ̇ ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl, ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡, ÍËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌÂ, ÍÓ„ÌËÚË‚ÂÌ ‰ÂÙˈËÚ. óÂÌÓ‰ӷ̇ڇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl (óÖ)  ˜ÂÒÚÓ ÛÒÎÓÊÌÂÌË ÔË Ô‡ˆËÂÌÚËÚÂ Ò ˆËÓÁ‡. éÍÓÎÓ 60% ÓÚ ‚Ò˘ÍË Ô‡ˆËÂÌÚË Ò ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡ ËÏ‡Ú Â‰Ì‡ ËÎË ‰Û„‡ ÒÚÂÔÂÌ Ì‡ óÖ. èÓ ‰‡ÌÌË Ì‡ Groeneweg (7) ÔË Ô‡ˆËÂÌÚËÚÂ Ò Child- Pugh A ‚ 14% ÔË Ô‡ˆËÂÌÚËÚÂ Ò Child-Pugh B/ë ‚ 45%  ̇Îˈ ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl. åÓÁ¸˜Ì‡Ú‡ ‰ËÒÙÛÌ͈Ëfl Ò Ô˘ËÌfl‚‡ ÔÓ ÏÂÚ‡·ÓÎËÚÂÌ Ô¸Ú Ë Ò ËÁ‡Áfl‚‡ ‚ ÔÓ-ÌÂÁ‡·ÂÎÂÊËÏË ËÎË ÔÓ-·˙ÁÓ Ì‡Ô‰‚‡˘Ë Ì‚ÓÔÒËı˘ÌË ÓÚÍÎÓÌÂÌËfl: ΢ÌÓÒÚÓ‚Ë, ‡ÙÂÍÚË‚ÌË, Ôӂ‰Â̘ÂÒÍË, ÍÓ„ÌËÚË‚ÌË, ̇Û¯ÂÌËfl ̇ Ò¸Ìfl, ÒÏÛ˘ÂÌËfl ‚˙‚ ÙË̇ڇ ÏÓÚÓË͇ ËÎË ÔÓ-fl‚ÌË ÂÙÎÂÍÒÌË, ÍÓÓ‰Ë̇ˆËÓÌÌË ËÎË „Ó‚ÓÌË Ì‡Û¯ÂÌËfl (2, 5). éÚÒ¸ÒÚ‚ËÂÚÓ Ì‡ fl‚ÌË Ì‚ÓÎӄ˘ÌË Ë ÔÒËı˘ÌË ÒËÏÔÚÓÏË Ì ËÁÍβ˜‚‡ ÒÍËÚ ÍÓ„ÌËÚË‚ÂÌ ‰ÂÙˈËÚ (͇ÚÓ Ô‰‚ÂÒÚÌËÍ Ì‡ ‡Á‚Ë‚‡˘‡ Ò ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl), ÍÓÈÚÓ ÒÚ‡‚‡ “‚ˉËÏ” Ô‰ËÏÌÓ Ò Ì‡ıÓ‰ÍË ÓÚ ÔÒËıÓÏÂÚ˘ÌÓ ÚÂÒÚ‚‡Ì (15, 19). èÂÁ ÔÓÒΉÌËÚ 15 „Ó‰ËÌË ÏÌÓÊÂÒÚ‚Ó ÔÓÛ˜‚‡ÌËfl ı‡‡ÍÚÂËÁË‡Ú ÍÓ„ÌËÚË‚ÌËfl ÔÓÙËΠ̇ ÏËÌËχÎ̇ڇ (ÒÛ·ÍÎËÌ˘̇) ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl (åóÖ) Ò ‰ËÒÍÂÚÌË ÔÓfl‚Ë Ì‡ Á‡·‡‚Â̇ ÔÒËıÓÏÓÚÓË͇, ‰ÂÙˈËÚ Ì‡ ‚ÌËχÌËÂÚÓ (ÔË Ò¸ı‡ÌÂÌ ËÌÚÂÎÂÍÚ), ÒÏÛ˘ÂÌËfl ‚˙‚ ÙË̇ڇ ÏÓÚÓË͇, ͇ÍÚÓ Ë ÌflÍÓË ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ‡·ÌÓÏÌÓÒÚË Ì‡ÒÓ˜‚‡˘Ë Í˙Ï ÏÓÁ¸˜Ì‡ ‰ËÒÙÛÌ͈Ëfl (11, 13, 20). ç‡Î˘ËÂÚÓ Ì‡ åóÖ Ì‡È-˜ÂÒÚÓ Ò¸‚Ô‡‰‡ Ò ÎÂÍËÚ ÒÚÂÔÂÌË Ì‡ ˜ÂÌÓ‰ӷ̇ Û‚‰‡ (1). ç‚ÓÔÒËı˘ÌËÚ ̇Û¯ÂÌËfl ÔË óÖ ÏÓ„‡Ú ‰‡ Ò Í·ÒËÙˈË‡Ú ÔÓ ÚÂÊÂÒÚ ÓÚ ÌÛ΂‡ ‰Ó ˜ÂÚ‚˙Ú‡ ÒÚÂÔÂÌ ‚Íβ˜ËÚÂÎÌÓ (Í·ÒËÙË͇ˆËfl ̇ West-Haven) (4). ìÒÚ‡ÌÓ‚fl‚‡ÌÂÚÓ Ë ‡Á„‡Ì˘‡‚‡ÌÂÚÓ Ì‡ åóÖ ÓÚ I ÒÚÂÔÂÌ Ì‡ óÖ Ò‡ ÌÂÎÂ͇ ÍÎËÌ˘̇ Á‡‰‡˜‡. ífl Úfl·‚‡ ‰‡ Ò ¯‡‚‡ ÛÚËÌÌÓ, Ú˙È Í‡ÚÓ Ì‡‚ÂÏ Á‡ÔӘ̇ÚÓÚÓ Î˜ÂÌË  ‚‡ÊÌÓ ÛÒÎÓ‚Ë Á‡ Ó„‡Ì˘‡‚‡Ì ËÎË Ó·‡ÚÌÓ ‡Á‚ËÚË ̇ Ì‚ÓÔÒËı˘ÌËÚ ̇Û¯ÂÌËfl. èË Ô‡ˆËÂÌÚËÚÂ Ò I ÒÚÂÔÂÌ Ì‡ ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl Ì‚ÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡Ì ÛÒÚ‡ÌÓ‚fl‚‡ ͇ÍÚÓ ‰ÂÙˈËÚ Ì‡ ‚ÌËχÌËÂÚÓ Ë ÍÓ̈ÂÌÚ‡ˆËflÚ‡, ڇ͇ Ë ÌflÍÓË fl‚ÌË ‰‚Ë„‡ÚÂÎÌË Ì‡Û¯ÂÌËfl: ‡ÒÚÂËÍÒËÒ, ˄ˉÌÓ Ôӂ˯ÂÌ ÏÛÒÍÛÎÂÌ ÚÓÌÛÒ, ÍÓÓ‰Ë̇ˆËÓÌÌË Ì‡Û¯ÂÌËfl Ë ‰. (3, 10). ÑÓ͇Á‡ÌÓ Â, ˜Â ‚ ÓÒÌÓ‚‡Ú‡ ̇ ÚÂÁË Ì‡È-˜ÂÒÚÓ ‰ËÒÍÂÚÌË Ì‚ÓÎӄ˘ÌË Ì‡ıÓ‰ÍË ÔË Ô‡ˆËÂÌÚËÚÂ Ò ÌËÒÍÓÒÚÂÔÂÌ̇ óÖ ÒÚÓflÚ ‰ËÒÙÛÌ͈ËË Ì‡ ·‡Á‡ÎÌËÚ „‡Ì„ÎËË, ˆÂ·Â·ÌËÚ Ô˙Úˢ‡, ͇ÍÚÓ Ë Ì‡ ‡Á΢ÌË ÍÓÓ‚Ë „ËÓÌË (14, 18). ÇÎÓ¯‡‚‡ÌÂÚÓ Ì‡ Ó·˘ÓÚÓ Ò˙ÒÚÓflÌËÂ Ë Ì··„ÓÔËflÚ̇ڇ ÔÓ„ÌÓÁ‡ ÔË Ô‡ˆËÂÌÚËÚÂ-ˆËÓÚËˆË Ò ̇ÏË‡Ú ‚ ÍÓ·ˆËfl Ò ‡Á‚ËÚËÂÚÓ Ë ÚÂÊÂÒÚÚ‡ ̇ óÖ (8). ñÖã KÎËÌ˘ÌÓ, ÔÒËıÓÏÂÚ˘ÌÓ Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ ÚÂÒÚ‚‡Ì ̇ Ô‡ˆËÂÌÚË Ò ÎÂ͇ ÒÚÂÔÂÌ Ì‡ ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡ Á‡ ̇΢ˠ(ËÎË ÓÚÒ˙ÒÚ‚ËÂ) ̇ ˜ÂÌÓ‰ӷ̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl. äéçíàçÉÖçí à åÖíéÑà ᇠÔÂËÓ‰ ÓÚ Â‰Ì‡ „Ó‰Ë̇ (ÓÍÚÓÏ‚Ë 2005 - ÓÍÚÓÏ‚Ë 2006 „Ó‰.) ‚ ÔÓÛ˜‚‡ÌÂÚÓ Ò‡ ‚Íβ˜ÂÌË 41 Ô‡ˆËÂÌÚ‡ Ò ‰Ó͇Á‡Ì‡ ‚ äÎËÌË͇ڇ ÔÓ „‡ÒÚÓÂÌÚÂÓÎÓ„Ëfl ̇ ìåÅÄã “ë‚. ÉÂÓ„Ë”- ÖÄÑ, èÎÓ‚‰Ë‚, ÎÂ͇ ÒÚÂÔÂÌ Ì‡ ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡(ÔÓ Í·ÒËÙË͇ˆËflÚ‡ ̇ Child-Pugh Ä Ë Child-Pugh

81

Ç). ë‰̇ڇ ‚¸Á‡ÒÚ Ì‡ Ô‡ˆËÂÌÚËÚ  55,56±6,79 „Ó‰. å¸ÊÂÚ ҇ ÔÂӷ·‰‡‚‡˘ ·ÓÈ (29 ϸÊÂ Ë 12 ÊÂÌË). ÇÒ˘ÍË Ô‡ˆËÂÌÚË Ò‡ Á‡ÔÓÁ̇ÚË Ò ‰ËÁ‡È̇ ̇ ÔÓÛ˜‚‡ÌÂÚÓ Ë Ò‡ ÔÓ‰ÔËÒ‡ÎË ËÌÙÓÏË‡ÌÓ Ò¸„·ÒË Á‡ Û˜‡ÒÚËÂ. Ç ÔÓÛ˜‚‡ÌÂÚÓ Ì ҇ ‚Íβ˜ÂÌË Ô‡ˆËÂÌÚË Ò: 1) ÑÛ„Ë Á‡·ÓÎfl‚‡ÌËfl ̇ ñçë, ‚Ó‰Â˘Ë ‰Ó Â̈ÂÙ‡ÎÓÔ‡ÚËfl: ÏÓÁ¸˜ÂÌ ËÌÒÛÎÚ, Ú‡‚ÏÂÌË, ‚¸ÁÔ‡ÎËÚÂÎÌË, ‚Ó‰ÂÌË Ë ‰Â„ÂÌÂ‡ÚË‚ÌË Á‡·ÓÎfl‚‡ÌËfl ̇ ñçë, ‚Íβ˜ËÚÂÎÌÓ Ô‡ÍËÌÒÓÌÓ‚‡ ·ÓÎÂÒÚ, Ô‡ÍËÌÒÓÌ ÔÎ˛Ò ÒË̉ÓÏË, ÔÂÒÂÌËÎÌË ‰ÂÏÂ̈ËË 2) ü‚ÌË Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË Á‡ ÏÓÁ˙˜Ì‡ ‰ËÒÙÛÌ͈Ëfl 3) íÂÊÍË Ò¸‰Â˜ÌË, ‰Ëı‡ÚÂÎÌË, ÔÒËıˇÚ˘ÌË, ·¸·˜ÌË Á‡·ÓÎfl‚‡ÌËfl, ‰ÂÍÓÏÔÂÌÒË‡Ì Á‡ı‡ÂÌ ‰Ë‡·ÂÚ 4) çÂıÂÔ‡Ú‡ÎÌË ÏÂÚ‡·ÓÎËÚÌË Â̈ÂÙ‡ÎÓÔ‡ÚËË (‰Ë‡·ÂÚ̇, ÛÂÏ˘̇, Ë ‰.) 5) чÌÌË Á‡ ÛÏÒÚ‚Â̇ ËÁÓÒڇ̇ÎÓÒÚ Ë Ó·‡ÁÓ‚‡ÚÂÎÌÓ ÌË‚Ó ÔÓ‰ 5 „Ó‰ËÌË 6) ç‡ÒÍÓÓ¯ÂÌ ÔËÂÏ (‰Ó 3 ÏÂÒˆ‡) ̇ ÔÒËıÓ‡ÍÚË‚ÌË ‚¢ÂÒÚ‚‡ (‡ÌÚˉÂÔÂÒ‡ÌÚË, Ò‰‡ÚË‚ÌË Ë ‰.) åÖíéÑà çÄ èêéìóÇÄçÖíé äÎËÌ˘ÌÓ ËÁÒΉ‚‡Ì ‚ ·ÓÎÌ˘ÌË ÛÒÎÓ‚Ëfl ÓÚ „‡ÒÚÓÂÌÚÂÓÎÓ„, Í¸‚ÌË Ë ·ËÓıËÏ˘ÌË ÔÓ͇Á‡ÚÂÎË, ‡·‰ÓÏË̇Î̇ ÂıÓ„‡ÙËfl, Á‡ ÛÒÚ‡ÌÓ‚fl‚‡Ì ÒÚÂÔÂÌÚ‡ ̇ ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡ (ÔÓ Í·ÒËÙË͇ˆËflÚ‡ ̇ ChildPugh). ● ñÂÎÂ̇ÒÓ˜Â̇ ‡Ì‡ÏÌÂÁ‡ ÓÚ Ì‚ÓÎÓ„ Ë Ì‚ÓÎӄ˘ÂÌ ÒÚ‡ÚÛÒ Á‡ ÛÒÚ‡ÌÓ‚fl‚‡Ì ̇ ·ÚÂÌÚÌË ËÎË fl‚ÌË Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË, ËÌÒÚÛÏÂÌÚ‡ÎÌË ËÁÒΉ‚‡ÌËfl (ÍÓÏÔ˛Ú˙̇ ÚÓÏÓ„‡ÙËfl, ‰ÓÔÎÂÓ‚‡ ÒÓÌÓ„‡ÙËfl) ‚ ÔÓ‰ÍÂÔ‡ ̇ ËÁ‚˙¯‚‡Ì‡Ú‡ ÒÂÎÂ͈Ëfl (ÒÔÓ‰ ËÁÍβ˜‚‡˘ËÚ هÍÚÓË Á‡ ÌÂıÂÔ‡Ú‡Î̇ Â̈ÂÙ‡ÎÓÔ‡ÚËfl). ● èÒËıÓÏÂÚ˘̇ ÓˆÂÌ͇ ̇ ÍÓ„ÌËÚË‚ÌÓÚÓ ÙÛÌ͈ËÓÌË‡ÌÂ Ò MMSE Ë Digit span (Ô‡‚ Ë Ó·‡ÚÂÌ ‰) ‚ ‰ÂÌfl ̇ ÒÌÂÚËfl Ì‚ÓÎӄ˘ÂÌ ÒÚ‡ÚÛÒ ● ÖÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ ËÁÒΉ‚‡Ì ̇ ÁËÚÂÎ̇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ Ò Hepatonorm-Analyser. è‡„˙Ú Ì‡ ÍËÚ˘̇ڇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (Critical flicker frequency - CFF) Ò ÓÔ‰ÂÎfl ÓÚ Ò‰̇ڇ ÒÚÓÈÌÓÒÚ Ì‡ 8 ËÁÏÂÂÌË ÂÁÛÎÚ‡Ú‡ ÔË ‚ÒÂÍË Ô‡ˆËÂÌÚ Ë Ò Ô‡‚Ë Ò¸ÔÓÒÚ‡‚͇ Ò ÔËÂÚËfl ÍËÚ˘ÂÌ Ô‡„ 39 Hz. (12) ● èÒËıÓÏÂÚ˘ÌÓÚ ÚÂÒÚ‚‡Ì Á‡ ÒÚÂÔÂÌ Ì‡ óÖ ÔÓ ÏÓ‰ËÙˈË‡Ì‡ Í·ÒËÙË͇ˆËfl ̇ West-Haven (4). ● ëÚ‡ÚËÒÚ˘ÂÒÍË ‡Ì‡ÎËÁ: ᇠÒ‡‚Ìfl‚‡Ì ̇ ÂÁÛÎÚ‡ÚËÚÂ, ÔÓÎÛ˜ÂÌË ‚ ‰‚ÂÚ ӷÓÒÓ·ÂÌË „ÛÔË (Child-Pugh Ä Ë Child-Pugh Ç) Ò‡ ËÁÔÓÎÁ‚‡ÌË ‚‡ˇˆËÓÌÂÌ ‡Ì‡ÎËÁ Ë one-way ANOVA. ë ÍÓ·ˆËÓÌÂÌ ‡Ì‡ÎËÁ  ÔÓ‚ÂÂ̇ ‚˙Á͇ڇ ÏÂÊ‰Û ‡Ì‡ÎËÁË‡ÌËÚ ÔÓÏÂÌÎË‚Ë. ●

êÖáìãíÄíà ë ıÂÔ‡ÚËÚ ë ‚ËÛÒ̇ ˆËÓÁ‡ Ò‡ 15 (37,6%) Ô‡ˆËÂÌÚË, Ò ıÂÔ‡ÚËÚ Ç ‚ËÛÒ̇ ˆËÓÁ‡ Ò‡ 7 (17,1%), Ë Ò ‡ÎÍÓıÓÎ̇ ÂÚËÓÎÓ„Ëfl Ò‡ 19 (46,3%) Ô‡ˆËÂÌÚ‡ (퇷Î. 1). èÓ-˜ÂÒÚË Ò‡ ̇ÎÍÓıÓÎÌËÚ ˆËÓÁË ÓÚ ÚËÔ Child-Pugh Ä, ‡ ÔË ÚËÔ Child-Pugh Ç ÔÂӷ·‰‡‚‡Ú ˆËÓÁËÚÂ Ò ‡ÎÍÓıÓÎ̇ ÂÚËÓÎÓ„Ëfl. ç‡ Ú‡·Î. 2 Ò‡ Ô‰ÒÚ‡‚ÂÌË ÛÒÚ‡ÌÓ‚ÂÌËÚ ÔÓ ‚ˉ Ë ˜ÂÒÚÓÚ‡ ‰ËÒÍÂÚÌË Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË (9 ̇ ·ÓÈ) Á‡ ÏÓÁ˙˜Ì‡ ‰ËÒÙÛÌ͈Ëfl, ̇ÏÂÂÌË ÔË 7 Îˈ‡ (17,1%) (ÓÚ ‚Ò˘ÍË 41 Ô‡ˆËÂÌÚË ËÁÒΉ‚‡ÌË Ì‚ÓÎӄ˘ÌÓ). éÚ Úflı Ò ÚËÔ Child-Pugh Ä Ò‡ 2 (4,8%) Ô‡ˆËÂÌÚË Ë ÓÚ ÚËÔ Child Pugh Ç Ò‡ 5 (12,2%) (퇷Î.2). èÓÎÛ˜ÂÌËÚ „ÛÔÓ‚Ë Ò‰ÌË ÒÚÓÈÌÓÒÚË ÓÚ ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡ÌÂ Ò Hepatonorm-Analyser Ë ÓÚ ËÁÔ˙ÎÌÂÌËÂÚÓ Ì‡ ÔÒËıÓÏÂÚ˘ÌËÚ ÚÂÒÚÓ‚Â ÔË ‰‚ÂÚÂ


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

82

Ta·Î. 1. ê‡ÁÔ‰ÂÎÂÌË ̇ Ô‡ˆËÂÌÚËÚ ÒÔÓ‰ ‚ˉ‡ ̇ ÛÒÚ‡ÌÓ‚ÂÌËÚ ÂÚËÓÎӄ˘ÌË Ù‡ÍÚÓË Ë ÒÚÂÔÂÌÚ‡ ̇ ˜ÂÌÓ‰ӷ̇ڇ ˆËÓÁ‡. Child-Pugh A Child-Pugh B é·˘Ó % ÅÓÈ % ÅÓÈ % ë ̇ÎÍÓıÓÎ̇ 14 34,1% 8 19,5% 22 53,6% ÂÚËÓÎÓ„Ëfl ë ‡ÎÍÓıÓÎ̇ 7 17,1% 12 29,3% 19 46,4% ÂÚËÓÎÓ„Ëfl é·˘Ó 21 51,2% 20 48,8% 41 100% „ÛÔË Ô‡ˆËÂÌÚË Ò‡ ÔÓ͇Á‡ÌË Ì‡ Ú‡·Î. 3. (퇷Î. 3). ë˙˘ËÚ ÂÁÛÎÚ‡ÚË, ÔÓÓÚ‰ÂÎÌÓ Ë „‡Ù˘ÌÓ Ò‡ Ô‰ÒÚ‡‚ÂÌË Ì‡ ÙË„. 1, 2, 3 Ë 4. (îË„.1, 2, 3, 4). ë ÍËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ ÔÓ‰ ÍËÚ˘ÌËfl Ô‡„ (39 Hz) ÓÚ „ÛÔ‡ Ä Ò‡ 4 (9,7%) Îˈ‡, ‡ ÓÚ „ÛÔ‡ Ç - 8 (19,5%). éÚ ‚Ò˘ÍËÚ 41 Îˈ‡, ËÁÒΉ‚‡ÌË ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ Ò Hepatonorm Analyser, 12 Ô‡ˆËÂÌÚË Ò‡ Ò ÔÓ͇Á‡ÚÂÎË ÔÓ‰ ÍËÚ˘ÌËfl Ô‡„ ̇ ÚÂÔÚÂÌÂ, Ë Ò‡ÏÓ ÔË 7 (17,1%) ÓÚ Úflı Ì‚ÓÎӄ˘ÌËfl ÒÚ‡ÚÛÒ Ì‡ÏË‡ ‰ËÒÍÂÚÌË Ì‡Û¯ÂÌËfl ‚˙‚ ÙË̇ڇ ÏÓÚÓË͇: ÔË 2 ÓÚ „ÛÔ‡ Ä Ë ÔË 5 ÓÚ „ÛÔ‡ Å. ä‡ÍÚÓ Ò ‚Ëʉ‡ ËÁÒΉ‚‡ÌËÚ Îˈ‡ ÓÚ „ÛÔ‡ “Ä” Ò ÒÔ‡‚flÚ ÔÓ-‰Ó·Â Ò ÚËÚ ÏÂÚÓ‰ËÍË, ÓˆÂÌfl‚‡˘Ë Ó·˘ÓÚÓ ÍÓ„ÌËÚË‚ÌÓ ÙÛÌ͈ËÓÌË‡ÌÂ, ‚ÌËχÌËÂÚÓ Ë Í‡ÚÍÓÒӘ̇ڇ ÒÎÓ‚ÂÒ̇ Ô‡ÏÂÚ Ë ÔÓ-fl‰ÍÓ ÔË Úflı ÒÚ‡‰‡ ÁË퇷Î. 2. êÂÁÛÎÚ‡ÚË ÓÚ Ì‚ÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡Ì ̇ Ô‡ˆËÂÌÚËÚÂ Ò ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡ ÑËÒÍÂÚÌË Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË ÑËÒÏÂÚËfl àÌÚÂ̈ËÓÌÂÌ ÚÂÏÓ ÑËÁ‡ÚËfl ĉˇ‰ÓıÓÍËÌÂÁËfl é·˘Ó

íËÔ Child – Pugh ÅÓÈ 1 1 2

íËÔ Child-Pugh Ç ÅÓÈ 3 1 2 2 7

ÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ. à ‚ ‰‚ÂÚ „ÛÔË Ò‰ÌËÚ ÒÚÓÈÌÓÒÚË ÓÚ MMSE Ò‡ ÔÓ‰ ÔËÂÚ‡Ú‡ ÒÚÓÈÌÓÒÚ Á‡ ÎËÔÒ‡ ̇ ̇Û¯ÂÌËfl ̇ ÍÓ„ÌËÚË‚ÌÓÚÓ ÙÛÌ͈ËÓÌË‡Ì – 28 Ú. Ç „ÛÔ‡ Ä, 8 Îˈ‡ ËÏ‡Ú ÂÁÛÎÚ‡Ú ÓÚ MMSE ÔÓ‰ „ÛÔÓ‚‡Ú‡ Ò‰̇ ÒÚÓÈÌÓÒÚ, ‡ 6 ÓÚ Úflı ËÏ‡Ú ÂÁÛÎÚ‡Ú „‡Ì˘ÂÌ ËÎË ÔÓ‰ „‡Ì˘ÌËfl Á‡ ÎÂÍ ‰ÂÏÂÌÚÂÌ ÒË̉ÓÏ. Ç „ÛÔ‡ Ç, 9 ÓÚ ËÁÒΉ‚‡ÌËÚ Îˈ‡ ËÏ‡Ú ÂÁÛÎÚ‡Ú ÔÓ‰ „ÛÔÓ‚‡Ú‡ Ò‰̇ ÒÚÓÈÌÓÒÚ, ÔÓ͇Á‚‡˘‡ ÎÂÍ ‰ÂÏÂÌÚÂÌ ÒË̉ÓÏ. ë‡ÏÓ ÔË Â‰ËÌ Ô‡ˆËÂÌÚ ÒÚÓÈÌÓÒÚÚ‡  „‡Ì˘̇ – 24 Ú. ᇠDigit span ‚ Ô‡‚ ‰ ÔÓ‰ „ÛÔÓ‚‡Ú‡ Ò‰̇ ÒÚÓÈÌÓÒÚ Ò‡ ÂÁÛÎÚ‡ÚËÚ ̇ 12 ËÁÒΉ‚‡ÌË Îˈ‡ ÓÚ „ÛÔ‡ Ä , ͇ÚÓ 6 (50%) ÓÚ Úflı Ò‡ Ò ÂÁÛÎÚ‡Ú 6 Ú. (ÔË 6,11 Ò‰̇ ÒÚÓÈÌÓÒÚ) Ë 9 Îˈ‡ ÓÚ „ÛÔ‡ Ç. ÇÒ˘ÍË Ô‡ˆËÂÌÚË Ò Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË ËÏ‡Ú ·‡ÎÓ‚Â Ë ÓÚ ‰‚‡Ú‡ ÚÂÒÚ‡

îË„. 1. ë‰̇ ÍËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ ÔË ‰‚ÂÚ „ÛÔË Ô‡ˆËÂÌÚË („ÛÔ‡ Ä – Ô‡ˆËÂÌÚË Ò Child-Pugh A, Ë „ÛÔ‡ Ç – Ô‡ˆËÂÌÚË Ò Child-Pugh B) ÔÓ‰ „ÛÔÓ‚ËÚ Ò‰ÌË. ë‡‚ÌÂ̇ Ò ÍÓ„ÌËÚË‚ÌÓÚÓ ÙÛÌ͈ËÓÌË‡ÌÂ, ÁËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ Â ÔÓ-fl‰ÍÓ Ì‡Û¯Â̇. ë‡‚ÌÂÌËÂÚÓ Ì‡ ÔÓÒÚËÊÂÌËflÚ‡ ‚ ‰‚ÂÚ „ÛÔË Ò ANOVA ÔÓ͇Á‚‡ ÒÚ‡ÚËÒÚ˘ÂÒÍË Á̇˜ËÏË ‡Á΢Ëfl ‚ ÂÁÛÎÚ‡ÚËÚ ÓÚ Ò‰̇ڇ ÍËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (mean flicker) F=7.94, p=0.008; MMSE – F=4.18, p=0.04; Digit span (‚ Ô‡‚ ‰ F=14.83, p < _ 0.001) Ë ‚ Ó·‡ÚÂÌ ‰ (F=16.14, p < _ 0.001). èÓÎÛ˜ÂÌËÚ ÂÁÛÎÚ‡ÚË ÓÚ ÍÓ·ˆËÓÌÂÌ ‡Ì‡ÎËÁ ̇ ·‡ÎÓ‚ÂÚ ÓÚ ÚËÚ ÏÂÚÓ‰ËÍË (‰‚‡Ú‡ ÔÒËıÓÏÂÚ˘ÌË ÚÂÒÚ‡ Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ ËÁÒΉ‚‡Ì ̇ ÁËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ) ÔÓ͇Á‚‡Ú, ˜Â ÎËÔÒ‚‡ ‚˙Á͇ ÏÂÊ‰Û ·‡Î‡ Á‡ Ó·˘ÓÚÓ ÍÓ„ÌËÚË‚ÌÓ ÙÛÌ͈ËÓÌË‡Ì (ÓˆÂÌÂÌÓ Ò MMSE) Ë Ò‰̇ڇ ÍËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (mean flicker) r=0.003, p=0,98; ͇ÍÚÓ Ë ÏÂÊ‰Û ·‡ÎÓ‚ÂÚ ÓÚ Digit span Ë Ò‰̇ڇ ÍËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (mean flicker) - ‚ Ô‡‚ ‰ r=0.19, p=0.24; ‚ Ó·‡ÚÂÌ ‰ r=0.26, p=0.11. é·˘ËflÚ ·‡Î ÓÚ MMSE  ‚ ‰Ó· ËÁ‡ÁÂ̇ Ë ÒÚ‡ÚËÒÚ˘ÂÒÍË Á̇˜Ëχ ÔÓÁËÚ˂̇ ‚˙Á͇ Ò ·‡ÎÓ‚ÂÚ ÓÚ Digit span (‚ Ô‡‚ ‰) r=0.61, p<0.001 Ë ÓÚ

Ta·Î. 3. ÉÛÔÓ‚Ë Ò‰ÌË ÒÚÓÈÌÓÒÚË ÓÚ ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡ÌÂ Ò Hepatonorm-Analyser Ë ËÁÔ˙ÎÌÂÌËÂÚÓ Ì‡ ÔÒËıÓÏÂÚ˘ÌËÚ ÚÂÒÚÓ‚Â ÔË ‰‚ÂÚ „ÛÔË Ô‡ˆËÂÌÚË. äËÚ˘̇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (CFF) MMSE Digit span forward Digit span backward

ÉÛÔ‡ Ä Ç A Ç Ä Ç Ä Ç

ë‰̇ 44.72 38.71 26.74 24.55 6.11 4.70 5.53 3.75

SD 5.17 5.47 3.18 3.49 1.24 1.03 1.17 155

îË„.2. ë‰ÌË ÒÚÓÈÌÓÒÚË ÓÚ ååSE ‚ ‰‚ÂÚ „ÛÔË Ô‡ˆËÂÌÚË („ÛÔ‡ Ä – Ô‡ˆËÂÌÚË Ò Child-Pugh A, Ë „ÛÔ‡ Ç – Ô‡ˆËÂÌÚË Ò Child-Pugh B)


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

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Digit span (‚ Ó·‡ÚÂÌ ‰) r=0.69, p<0.001). éÅëöÜÑÄçÖ èӂ‰ÂÌÓÚÓ ‚ ·ÓÎÌ˘̇ Ó·ÒÚ‡Ìӂ͇ ÍÎËÌ˘ÌÓÚÓ ËÁÒΉ‚‡Ì ̇ Ô‡ˆËÂÌÚË Ò ˜ÂÌÓ‰Ó·ÌÓ Û‚Âʉ‡Ì ÛÚ‚˙‰Ë ÔÓ ÍËÚÂËËÚ Á‡ ˜ÂÌÓ‰ӷ̇ ˆËÓÁ‡ ÒÚÂÔÂÌ Child-Pugh Ä ÔË 21 Ô‡ˆËÂÌÚ‡, Ë Á‡ ÒÚÂÔÂÌ Child-Pugh Ç ÔË 20 Ô‡ˆËÂÌÚ‡. ÇÍβ˜ËıÏ ԇˆËÂÌÚË Ò Ì‡ÎÍÓıÓÎ̇ (ıÂÔ‡ÚËÚ ë Ë ıÂÔ‡ÚËÚ Ç ‚ËÛÒ̇ ÂÚËÓÎÓ„Ëfl) Ë ‡ÎÍÓıÓÎ̇ ÂÚËÓÎÓ„Ëfl ̇ ˆËÓÁ‡Ú‡. éÒ‚ÂÌ Ì‡ÎÍÓıÓÎÌË ˆËÓÁË Ò ‚ËÛÒÂÌ ÔÓËÁıÓ‰ ‰Û„Ë ‡‚ÚÓË ‚Íβ˜‚‡Ú Ë ˆËÓÁË ‚ ÂÁÛÎÚ‡Ú Ì‡ ‡‚ÚÓËÏÛÌÂÌ ıÂÔ‡ÚËÚ, Ô˙‚˘̇ ·ËΡ̇ ˆËÓÁ‡, ıÂÏÓıÓχÚÓÁ‡ Ë ‰., ͇ÍÚÓ Ë Ò˙Ò ÒÚÂÔÂÌ Child – Pugh C (12, 16). ᇠÒÂÎÂÍÚË‡Ì ̇ Ô‡ˆËÂÌÚËÚÂ Ò åóÖ Ë ÎÂÍÓÒÚÂÔÂÌ̇ óñ (Child-Pugh - A Ë B) ‚ ÔÓÛ˜‚‡ÌÂÚÓ Ò ÔËÎÓÊË ÍÓÏ·Ë̇ˆËfl ÓÚ 3 ÏÂÚÓ‰ËÍË – ÔÒËıÓÏÂÚ˘ÌË ÚÂÒÚÓ‚Â, Ì‚ÓÎӄ˘ÌÓ Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ ËÁÒΉ‚‡ÌÂ. 阇͂‡ÌËÚ (ÓÚ Ì‚ÓÎӄ˘ÌËfl ÒÚ‡ÚÛÒ) ‰ËÒÍÂÚÌË ‰‚Ë„‡ÚÂÎÌË Ì‡Û¯ÂÌËfl ‚˙‚ ÙË̇ڇ ÏÓÚÓË͇ Ò ÛÒÚ‡ÌÓ‚fl‚‡Ú ˜ÂÒÚÓ ÔË Ô‡ˆËÂÌÚËÚÂ Ë ÓÚ ‰‚ÂÚ „ÛÔË Ò‡ÏÓ ‚ 17% ÓÚ ÒÎÛ˜‡ËÚÂ. ëΉӂ‡ÚÂÎÌÓ ÚÓÁË Â Ô‰‚‡ËÚÂÎÌÓ Ë ÛÚËÌÌÓ Ì‡ÏÂÂÌËfl (ÓÚ Ì‚ÓÎӄ˘ÌËfl ÒÚ‡ÚÛÒ) ÓÚÌÓÒËÚÂÎÂÌ ‰flΠ̇ ÒÎÛ˜‡ËÚÂ, ÔË ÍÓËÚÓ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ËÁÔ˙ÎÌÂÌË ÍËÚÂËËÚ Á‡ åóÖ, ‡ÍÓ Ò Ò˙˜ÂÚ‡flÚ Ò Ì‡ıÓ‰ÍË ÓÚ ÒΉ‚‡˘ËÚ ÔÒËıÓÏÂÚ˘ÌÓ ËÎË ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ ËÁÒΉ‚‡ÌÂ. Ç ÔÓÛ˜‚‡ÌÂÚÓ Ì‡ Mechtcheriakov (16) Ò ‰ÓÍ·‰‚‡ ÔÓ-‚ËÒÓÍ ÓÚÌÓÒËÚÂÎÂÌ ‰flΠ̇ ‰ËÒÍÂÚÌËÚ ‰‚Ë„‡ÚÂÎÌË Ì‡Û¯ÂÌËfl – ÔË 40 Ô‡ˆËÂÌÚË Ò ˆËÓÁ‡ Ò ÓÚ˜ËÚ‡Ú ‚ 45% ‡‰Ë‡‰ÓıÓÍËÌÂÁËfl, ‚ 22,5% - ‰ËÒÏÂÚËfl ̇ „ÓÔÌË Í‡ÈÌˈË, ‚ 10% - ‰ËÁ‡ÚËfl Ë Ú.Ì. ÇÂÓflÚÌÓ ÚÓÁË ‚ËÒÓÍ ÓÚÌÓÒËÚÂÎÂÌ ‰flΠ̇ Ì‚ÓÎӄ˘ÌËÚ ̇ıÓ‰ÍË Ò ‰˙ÎÊË Ì‡ Ù‡ÍÚ‡, ˜Â ÓÒ‚ÂÌ Ô‡ˆËÂÌÚË Ò åóÖ Ò‡ ËÁÒΉ‚‡ÌË Ë Ô‡ˆËeÌÚË Ò I ÒÚÂÔÂÌ Ì‡ óÖ. Ç˙ÁÏÓÊÌÓÚÓ Ú˙ÎÍÛ‚‡Ì ̇ ÂÁÛÎÚ‡ÚËÚ ÓÚ ÍÓ·ˆËÓÌÌËfl ‡Ì‡ÎËÁ ̇ ÔÓ͇Á‡ÚÂÎËÚ ÓÚ ÔÒËıÓÏÂÚ˘ÌËÚ ÚÂÒÚÓ‚Â Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡Ì Ì ÏÓÊ ‰‡ Ò ̇Ô‡‚Ë Â‰ÌÓÒÚ‡ÌÌÓ: è˙‚Ó: ãËÔÒ‡Ú‡ ̇ ÍÓ·ˆËfl ÏÂÊ‰Û ·‡ÎÓ‚ÂÚ Á‡ Ó·˘Ó ÍÓ„ÌËÚË‚ÌÓ ÙÛÌ͈ËÓÌË‡Ì (ÓÚ ÔËÎÓÊÂÌËÚ ÔÒËıÓÏÂÚ˘ÌË ÚÂÒÚÓ‚Â) Ë ÍËÚ˘̇ڇ ˜ÂÒÚÓÚ‡ ̇ ÚÂÔÚÂÌ (Ò Hepatonorm-Analyser) ÏÓÊ ‰‡ Ò ӷflÒÌË Ò Ù‡ÍÚ‡, ˜Â ÔÒËıÓÏÂÚ˘ÌËÚ ÚÂÒÚÓ‚Â ÓÚÍË‚‡Ú ̇΢ËÂÚÓ Ì‡ ÍÓ„ÌËÚË‚ÂÌ ‰ÂÙˈËÚ ‚˙Ó·˘Â, ‡ Ì ҇ÏÓ ‚ ÒÎÛ˜‡ËÚ ̇ óÖ. Ç˙ÔÂÍË ÔÓ-‡Ì̇ڇ Ò‰̇ ‚˙Á‡ÒÚ Á‡ ‚ÂÌÚÛ‡ÎÌÓ Ò˙Ô˙ÚÒÚ‚‡˘‡ åëÅ ÔË Ì‡·Î˛‰‡‚‡ÌËÚ ԇˆËÂÌÚË Ì ÏÓÊ ‰‡ Ò ËÁÍβ˜Ë ÌÂÈÌÓ ‚ÎËflÌË ‚˙ıÛ ‡·ÌÓÏÌËÚ ·‡ÎÓ‚Â, ‰Ó͇ÚÓ ÂÁÛÎÚ‡ÚËÚ ÓÚ ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓÚÓ ËÁÒΉ‚‡Ì ÏÓ„‡Ú ‰‡ ·˙‰‡Ú Ò‚˙Á‡ÌË Ò ÍÓÌÍÂÚÌÓ Ó„‡Ì˘ÌÓ Û‚Âʉ‡Ì ̇ ÂÚË̇ڇ, ‰˙Îʇ˘Ó Ò ̇ óÖ (6, 17). ÇÚÓÓ: ê‡ÌÌÓÚÓ ÂÚË̇ÎÌÓ „ΡÎÌÓ Û‚Âʉ‡Ì ÔË óÖ Ì‡È-‚ÂÓflÚÌÓ Á‡ÚÛ‰Ìfl‚‡ ÁËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ Ò˙Ò Á‡·‡‚flÌ ̇ ‚˙ÁÔËÂχÌÂÚÓ Ë ‡Á„‡Ì˘‡‚‡ÌÂÚÓ Ì‡ Ó·‡ÁËÚ (9). íÂÚÓ: åÓÊ ‰‡ Ò Ô‰ÔÓ·„‡, ˜Â ̇Û¯Â̇ڇ ÁËÚÂÎ̇ ‰ËÒÍËÏËÚ˂̇ ÒÔÓÒÓ·ÌÓÒÚ Ì Ò˙Ô˙ÚÒÚ‚‡ Û‚Âʉ‡ÌÂÚÓ Ì‡ ‚Â·‡Î̇ڇ Í‡ÚÍÓ‚ÂÏÂÌ̇ Ô‡ÏÂÚ Ë ‰Û„ËÚ ÒÔÓÒÓ·ÌÓÒÚË, ÓˆÂÌfl‚‡ÌË ÓÚ ÒÛ·ÚÂÒÚÓ‚ÂÚ ̇ MMSE (ÓËÂÌÚ‡ˆËfl, ÍÓ̈ÂÌÚ‡ˆËfl, ÁËÚÂÎÌÓÔÓÒÚ‡ÌÒÚ‚Â̇ ÒÔÓÒÓ·ÌÓÒÚ, ˜ Ë Ô‡ÍÒËÒ). óÂÚ‚˙ÚÓ: Ç Ò˙˘ÓÚÓ ‚ÂÏ ̇¯ËÚ ÂÁÛÎÚ‡ÚË ÔÓ͇Á‚‡Ú Á̇˜ËÏÓ ÔÓ-ÌËÒÍË ·‡ÎÓ‚Â ÓÚ MMSE Ë Digit span ‚ Ô‡‚ Ë Ó·‡ÚÂÌ ‰ ‚ „ÛÔ‡ “Ç”, ‚ ÍÓflÚÓ ÛÒÚ‡ÌÓ‚ÂÌËÚ Ì‚ÓÎӄ˘ÌË ÒËÏÔÚÓÏË Ò‡ ÔÓ‰˜ÂÚ‡ÌÓ ÔÓ-˜ÂÒÚË, ‚ Ò‡‚ÌÂÌËÂ Ò ÚÂÁË ÓÚ „ÛÔ‡ “Ä”. èÓ-ÌËÒÍËÚ ÓÚ „ÛÔÓ‚ËÚ Ò‰ÌË ÒÚÓÈÌÓÒÚË Ì‡ ·‡ÎÓ‚ÂÚ ÓÚ MMSE Ë Digit span ̇ ‚Ò˘ÍË ËÁÒΉ‚‡ÌË Îˈ‡, ÔË ÍÓËÚÓ ·flı‡ ̇ÏÂÂÌË Ì‚Ó-

îË„ 3. ë‰ÌË ÒÚÓÈÌÓÒÚË ÓÚ Digit span – forward ÔË ‰‚ÂÚ „ÛÔË Ô‡ˆËÂÌÚË („ÛÔ‡ Ä – Ô‡ˆËÂÌÚË Ò Child-Pugh A, Ë „ÛÔ‡ Ç – Ô‡ˆËÂÌÚË Ò Child-Pugh B) Îӄ˘ÌË ÒËÏÔÚÓÏË ÔÓ͇Á‚‡Ú, ˜Â ÚÂÁË ÚÂÒÚÓ‚Â ÏÓ„‡Ú ‰‡ ÓˆÂÌfl‚‡Ú ̇ÒÚ˙ÔËÎËÚ ÍÓ„ÌËÚË‚ÌË ÔÓÏÂÌË ‚ ÔÓÎÁ‡ ̇ Ú‡ÁË ‰Ë‡„ÌÓÁ‡. àáÇéÑà èӂ‰ÂÌÓÚÓ ÍÎËÌ˘ÌÓ, ÔÒËıÓÏÂÚ˘ÌÓ Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌÓ ÚÂÒÚ‚‡Ì ̇ Ô‡ˆËÂÌÚË Ò ÎÂÍÓÒÚÂÔÂÌ̇ óñ ÒÂÎÂÍÚË‡ ÒÎÛ˜‡Ë ̇ åóÖ ‚ ÔË·ËÎËÁËÚÂÎÌÓ 1/5 ÓÚ ÒÎÛ˜‡ËÚ àÁÒΉ‚‡ÌÂÚÓ Ì‡ ÁËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ Ò Hepatonorm-Analyser  ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÂÌ ÏÂÚÓ‰, ÍÓÈÚÓ ÛÚËÌÌÓ Ë Ô‚‡ÌÚË‚ÌÓ (ÔË ÓÚÒ˙ÒÚ‚Ë ̇ Ì‚ÓÎӄ˘̇ ÒËÏÔÚÓχÚË͇) ̇ÒÓ˜‚‡ Í˙Ï “‚˙ÁÏÓÊ̇” óÖ Ë ÌÂÓ·ıÓ‰ËÏÓÒÚÚ‡ ÓÚ ÔÓ-̇ڇÚ˙¯ÌÓ ÏÓÌËÚÓË‡Ì ̇ Ô‡ˆËÂÌÚËÚÂ Ò ÎÂÍÓÒÚÂÔÂÌ̇ óñ. ë˙˜ÂÚ‡ÌËÂÚÓ Ì‡ ‰‚‡ ÓÚ ÓÒÌÓ‚ÌËÚ ÍËÚÂËË Á‡ åóÖ: ‰ËÒÍÂÚÌË Ì‡Û¯ÂÌËfl ‚˙‚ ÙË̇ڇ ÏÓÚÓË͇ Ë ÂÎÂÍÚÓÙËÁËÓÎӄ˘ÌË ‡·ÌÓÏÌÓÒÚË (̇Û¯ÂÌËfl ‚ ÁËÚÂÎ̇ڇ ‰ËÒÍËÏË̇Ú˂̇ ÒÔÓÒÓ·ÌÓÒÚ)  ÔÓ-fl‰Í‡ ̇ıӉ͇ ÔË Ô‡ˆËÂÌÚËÚÂ Ò ÎÂÍÓÒÚÂÔÂÌ̇ óñ ‚ Ò‡‚ÌÂÌËÂ Ò ÔÓ-˜ÂÒÚËÚ ̇Û¯ÂÌËfl ̇ ÍÓ„ÌËÚË‚ÌÓÚÓ ÙÛÌ͈ËÓÌË‡ÌÂ. èÓˆÂ-

îË„.4. ë‰ÌË ÒÚÓÈÌÓÒÚË ÓÚ Digit span – backward ÔË ‰‚ÂÚ „ÛÔË Ô‡ˆËÂÌÚË („ÛÔ‡ Ä – Ô‡ˆËÂÌÚË Ò Child-Pugh A, Ë „ÛÔ‡ Ç – Ô‡ˆËÂÌÚË Ò Child-Pugh Ç)


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

ÒËÚ Ì ҇ Ô‡‡ÎÂÎÌË Ë Â‰ÌÓ‚ÂÏÂÌÌË Ë Ì ӷÂÍÚË‚ËÁË‡Ú ÒËÌıÓÌ̇ ‚‡ÎˉÌÓÒÚ ‚ ̇˜‡ÎÌËÚ ÂÚ‡ÔË ÓÚ ‡Á‚ËÚË ̇ óÖ - åóÖ. ìÒÚ‡ÌÓ‚Â̇ڇ Á̇˜ËÚÂÎ̇ Ë Á̇˜Ëχ ‚˙Á͇ ÏÂÊ‰Û Ó·˘Ëfl ·‡Î ÓÚ MMSE Ë ·‡ÎÓ‚ÂÚ ÓÚ Digit span ÛÚ‚˙ʉ‡‚‡ ËÁÔÓÎÁ‚‡ÌËÚ ÔÒËıÓÏÂÚ˘ÌË ÚÂÒÚӂ ͇ÚÓ ÔÓ‰ıÓ‰fl˘Ë ËÌÒÚÛÏÂÌÚË Á‡ ÓˆÂÌ͇ ̇ Í‡ÚÍÓ‚ÂÏÂÌ̇ Ô‡ÏÂÚ Ë ‚ÌËχÌË ͇ÚÓ ‰ÓÔ˙΂‡˘Ë ÍËÚÂËË ‚ ÔÓˆÂÒ‡ ̇ ‰Ë‡„ÌÓÒÚˈË‡ÌÂÚÓ Ì‡ åóÖ. Å·„Ó‰‡ÌÓÒÚ: Ä‚ÚÓËÚ ËÁ͇Á‚‡Ú ·Î‡„Ó‰‡ÌÓÒÚ Ì‡ ÙËχ “LIBRA” Á‡ Ô‰ÓÒÚ‡‚Â̇ڇ ‚˙ÁÏÓÊÌÓÒÚ Á‡ ÔÓÎÁ‚‡Ì ̇ Hepatonorm-Analyser. ãàíÖêÄíìêÄ 1.Amodio, P., Montagnese, S., Gatta, A., et al. Characteristics of minimal hepatic encephalopathy. Metab Brain Dis, 19, 2004, 253-264 2.Butterworth, R.F. Complications of cirrhosis. III. Hepatic encephalopathy. J Hepatol, 32, 2000, 171-180 3.Cadranel, J.F., Lebiez, E., Di Martino, V. Focal neurological signs in hepatic encephalopathy in cirrhotic patients: An underestimated entity? Am J Gastroneterol, 96, 2001, 515-518 4.Conn, H.O., Bircher, J. (Eds). Hepatic encephalopathy: Syndromes and therapies. Medi-Ed Press, !994, Bloomington, Illinois. 5.Das, A., Dhiman, R.K., Saraswat, V.A., et al. Prevalence and natural history of subclinical hepatic encephalopathy in cirrhosis. J Gastroenterol Hepatol, 16, 2001, 531-535 6.Eckstein, A.K., Reichenbach, A., Jacobi, P., et al. Hepatic retinopathia. Changes in retinal function. Vision res, 37, 1997, 1699-1706 7.Groeneweg, M., Moerland, W., Querro, J., et al. Screening of subclinical hepatic encephalopathy. J Hepatol, 32, 2000, 5, 748-753 8.Hartmann, I.J., Groeneweg, M., Quero, J.C., et al. The prognostic significance of subclinical hepatic encephalopathy. Am J Gastroenterol, 95(8), 2000, 20129-2034. 9.Haussinger, D., Kircheis, G., Fischer, R., et al. Hepatic encephalopathy in chronic liver disease: a clinical manifestation of astrocyte swelling and chronic low grade cerebral edema? J Hepatol, 32, 2000, 1035-1038 10.Hilsabeck, R.C., Perry, W., and Hassanein, T.I. Neuropsychological impairment in patients with chronic hepatitis C. Hepatology, 35, 2002, 440-446 11.Kharbanda, P.S., Saraswat, V.A., Dhiman, R.K., et al. Minimal hepatic

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encephalopathy: diagnosis by neuropsychological and neurophysiologic methods. Indian J Gastroenterol, 22, 2003, 2, S37-S41 12.Kircheis, G., Wettstein, M., Timmermann., L., et al. Critical flicker frequency for quantification of lo-grade hepatic encephalopathy. Hepatology, 35, 2002, 357366 13.Krieger, S., Jauss, M., Jansen, O., et al. Neuropsychiatric profile and hyperintense globus pallidus on T1-weighted magnetic resonance images in liver cirrhosis. Gastroeneterology, 111, 1996, 147-155 14.Lockwood, A.H., Weissenborn, K., Bokemeyer, M., et al. Correlations between cerebral glucose metabolism and neuropsychological test performance in nonalcoholic cirrhotics. Metab Brain Dis, 17, 2002, 29-40 15.Mattarozzi, K., Campi, C., Guarino, M., et al. Distinguishing between clinical and minimal hepatic encephalopathy on the basis of specific cognitive impairment. Metab Brain Dis, 20, 2005, 3, 243- 249 16.Mechtcheriakov, S., Graziadei, I.W., Rettenbacher, M., et al. Diagnostic value of fine motor deficits in patients with low-grade hepatic encephalopathy. World J Gastroenterol, 11, 2005, 18, 2777-2780 17.Reichenbach, A., Fuchs, U., Kasper, M., et al. Hepatis retinopathy: morphological features of retinal glial (Muller) cells accompanying hepatic failure. Acta Neuropathol, 90, 1995, 273-281. 18.Timmermann, I., Gross, J., Kircheis, G., et al. Cortical origin of mini-asterixis in hepatic encephalopathy. Neurology, 58, 2002, 295-298 19.Watanabe, A., Kuwabara, Y., Okita, H., et al. Computer-assisted quantitative neuropsychological tests for early detection of subclinical hepatic encephalopathy in patients with liver cirrhosis. Res Commun Biol Psychol Psychiatry, 22, 1997, 25-38 20.Weissenborn, K., Heidenreich, S., Ennen, J., et al. Attention deficits in minimal hepatic encephalopathy. Metab Brain Dis, 16, 2001, 13-19

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: Ñ- èÂÌ͇ Äڇ̇ÒÓ‚‡, ‰.Ï. É·‚ÂÌ ‡ÒËÒÚÂÌÚ äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl, å‰ˈËÌÒÍË ìÌË‚ÂÒËÚÂÚ ÅÛÎ. ◊LJÒËÎ ÄÔËÎÓ‚” 15Ä èÎÓ‚‰Ë‚, 4000 íÂÎ: 0888 837 352, 032 649 939 Fax: 032 620 402 Ö-mail: p_a7@abv.bg

éË„Ë̇ÎÌË ÒÚ‡ÚËË ìãíêÄáÇìäéÇé ÑìèãÖäë – ëäÖçàêÄçÖ çÄ ëöççàíÖ ÄêíÖêàà èêà Åéãçà ëöë áÄïÄêÖç ÑàÄÅÖí à ÑàÄÅÖíçÄ çÖÇêéèÄíàü è. чÏflÌÓ‚, ç. ÑËÏ. ÑËÏËÚÓ‚, ç. ÑÓÒ. ÑËÏËÚÓ‚, ã. á‡ÔflÌÓ‚‡, Ç. ÑËÏËÚÓ‚‡, Ñ.ÅÓ„‰‡ÌÓ‚‡, à. ÇÂΘ‚‡ åì – ëÓÙËfl, ìëÅÄã ÔÓ Ì‚ÓÎÓ„Ëfl Ë ÔÒËıˇÚËfl “ë‚. ç‡ÛÏ” SUMMARY ULTRASOUND DUPLEX-SCANNING OF THE CAROTID ARTERIES IN PATIENTS WITH DIABETES MELLITUS AND DIABETIC NEUROPATHY P. Damianov, N. Dim. Dimitrov, N. Dos. Dimitrov, L. Zaprianova, V. Dimitrova, D. Bogdanova, I. Velcheva It is known, that diabetes mellitus is a risk factor for development of atherosclerosis of the carotid and cerebral arteries and stroke. The aim of the study is to assess possible atherosclerotic changes of the carotid arteries by means of ultrasound duplexscanning in patients with diabetes mellitus and diabetic neuropathy and to search correlations with other risk factors for cerebrovascular disease. The study is carried out in 28 patients (18 women and 10 men at mean age of 63,6 ± 8,7 years ). Twenty five of the patients have diabetes type 2 and 3 patients have diabetes type 1. All patients underwent thorough clinical and neurological examination, including estimation of serum lipids and blood glucose. By means of ultrasound duplex-scanning of the common carotid (CCA) and internal carotid arteries (ICA) the presence and type of atherosclerotid plaques, the intima-

media thickness (IMT) and the blood flow velocity parameters are evaluated. The results of the clinical and the ultrasound investigation are compared to a control group of 16 presumed healthy subjects at the same age range. Heterogenous atherosclerotic plagues in the ICA, which lead to low-degree stenoses of 10% to 25% predominate in the patients with diabetic neuropathy. They are found in 9 patients in the LICA , in 12 patients in the RICA and in 7 patients bilaterally. íhrombosis of the LICA is observed in one patient. Only 2 patients have bilateral heterogenenous plaques in the CCA and another 3 have stenoses of these arteries of 25% to 49%.. The measurement of the IMT reveals significant thickening of the CCA and ICA vessel walls in comparison to the healthy controls. The IMT of the ICA (LICA, RICA and average) correlates significantly with the cholesterol and triglyceride values in the patients with diabetic neuropathy. The verification of early atherosclerosis of the carotid arteries in the patients with diabetic neuropathy provides opportunity for appropriate stroke prevention. KEY WORDS: atherosclerotic plaques, diabetic neuropathy, duplex-scanning, intima-media complex, carotid arteries.


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

êÖáûåÖ àÁ‚ÂÒÚÌÓ Â, ˜Â Á‡ı‡ÌËflÚ ‰Ë‡·ÂÚ Â ËÒÍÓ‚ Ù‡ÍÚÓ Á‡ ‡Á‚ËÚË ̇ ‡ÚÂÓÒÍÎÂÓÁ‡ ̇ ͇ÓÚˉÌËÚÂ Ë ÏÓÁ˙˜ÌËÚ ‡ÚÂËË Ë ÏÓÁ˙˜ÌË ËÌÒÛÎÚË. ñÂΠ̇ ÔÓÛ˜‚‡ÌÂÚÓ Â ÔÓÒ‰ÒÚ‚ÓÏ ÛÎÚ‡Á‚ÛÍÓ‚Ó ‰ÛÔÎÂÍÒ – ÒÍÂÌË‡Ì ̇ χ„ËÒÚ‡ÎÌËÚ ‡ÚÂËË Ì‡ „·‚‡Ú‡ ‰‡ Ò ÔÓÚ˙ÒflÚ ‰‡ÌÌË Á‡ ‡ÚÂÓÒÍÎÂÓÚ˘ÌË ÔÓÏÂÌË Ì‡ ͇ÓÚˉÌËÚ ‡ÚÂËË ÔË ·ÓÎÌË Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ë ‰Ë‡·ÂÚ̇ Ì‚ÓÔ‡ÚËfl, ͇ÍÚÓ Ë ÚÂıÌË ÍÓ·ˆËË Ò ‰Û„Ë ËÒÍÓ‚Ë Ù‡ÍÚÓË Á‡ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚‡ ·ÓÎÂÒÚ. àÁÒΉ‚‡ÌË Ò‡ 28 ·ÓÎÌË (18 ÊÂÌË Ë 10 Ï˙Ê ̇ Ò‰̇ ‚˙Á‡ÒÚ 63,6 ± 8,7 „Ó‰ËÌË). Ñ‚‡‰ÂÒÂÚ Ë ÔÂÚ ÓÚ ·ÓÎÌËÚ ҇ Ò ‰Ó͇Á‡Ì Á‡ı‡ÂÌ ‰Ë‡·ÂÚ 2 ÚËÔ Ë ÚËχ ·ÓÎÌË Ò 1 ÚËÔ. èË ‚Ò˘ÍË Â Ôӂ‰ÂÌÓ ÔÓ‰Ó·ÌÓ ÍÎËÌ˘ÌÓ ËÁÒΉ‚‡ÌÂ, ÍÓÂÚÓ ‚Íβ˜‚‡ ÒÓχÚ˘ÂÌ Ë Ì‚ÓÎӄ˘ÂÌ ÒÚ‡ÚÛÒ, ÓÔ‰ÂÎflÌ ̇ ÒÂÛÏÌËÚ ÎËÔˉË, Í˙‚ÌÓÁ‡ı‡ÂÌ ÔÓÙËÎ. èÓÒ‰ÒÚ‚ÓÏ ˆ‚ÂÚÌÓ ‰ÛÔÎÂÍÒ-ÒÍÂÌË‡Ì ̇ Ó·˘ËÚ (éëÄ) Ë ‚˙Ú¯ÌËÚ Ò˙ÌÌË ‡ÚÂËË (ÇëÄ) Ò‡ ÓˆÂÌfl‚‡ÌË Ì‡Î˘ËÂÚÓ Ë ‚ˉ‡ ̇ ‡ÚÂÓÒÍÎÂÓÚ˘ÌË Ô·ÍË, ‰Â·ÂÎË̇ڇ ̇ ËÌÚËχ-ωˇ ÍÓÏÔÎÂÍÒ‡ (àåä) Ë ÒÍÓÓÒÚÌËÚ ԇ‡ÏÂÚË Ì‡ Í˙‚ÌËfl ÚÓÍ. êÂÁÛÎÚ‡ÚËÚ ÓÚ ÍÎËÌ˘ÌÓÚÓ Ë ÛÎÚ‡Á‚ÛÍÓ‚ÓÚÓ ËÁÒΉ‚‡Ì ҇ Ò‡‚ÌÂÌË Ò ÚÂÁË Ì‡ ÍÓÌÚÓÎ̇ „ÛÔ‡ ÓÚ 16 ÍÎËÌ˘ÌÓ Á‰‡‚Ë Îˈ‡ ‚ Ò˙˘Ëfl ‚˙Á‡ÒÚÓ‚ ‰Ë‡Ô‡ÁÓÌ. èË ·ÓÎÌËÚ Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ë ‰Ë‡·ÂÚ̇ ÔÓÎËÌ‚ÓÔ‡ÚËfl ÔÂӷ·‰‡‚‡Ú ıÂÚÂÓ„ÂÌÌË ‡ÚÂÓÒÍÎÂÓÚ˘ÌËÚ Ô·ÍË ‚˙‚ ÇëÄ, ‚Ó‰Â˘Ë ‰Ó ÌËÒÍÓÒÚÂÔÂÌÌË ÒÚÂÌÓÁË ÓÚ 10% ‰Ó 25%.í Ò Ò¢‡Ú ÔË 9 ·ÓÎÌË ‚ ãÇëÄ, ÔË 12 ·ÓÎÌË ‚ ÑÇëÄ Ë ÔË 7 ·ÓÎÌË ‰‚ÛÒÚ‡ÌÌÓ. èË 1 ·ÓÎÂÌ Â Ì‡ÏÂÂ̇ ÚÓÏ·ÓÁ‡ ̇ ãÇëÄ. Ç éëÄ ‰‚ÛÒÚ‡ÌÌË ÌËÒÍÓÒÚÂÔÂÌÌË ÒÚÂÌÓÁË Ò‡ ̇·Î˛‰‡‚‡ÌË ÔË 2 ·ÓÎÌË. ïÂÚÂÓ„ÂÌÌË Ô·ÍË, ÒÚÂÌÓÁË‡˘Ë ÎÛÏÂ̇ ̇ Ò˙‰‡ ÏÂÊ‰Û 25 Ë 49% Ò‡ ÛÒÚ‡ÌÓ‚ÂÌË ÔË 2 ·ÓÎÌË ‚ ãéëÄ , ‡ ÔË1 ·ÓÎÂÌ ‚ ÑéëÄ. àÁÏÂ‚‡ÌÂÚÓ Ì‡ àåä ÔÓ͇Á‚‡ Á̇˜ËÏÓ Á‡‰Â·ÂÎfl‚‡Ì ̇ Ò˙‰Ó‚ËÚ ÒÚÂÌË ÔË ·ÓÎÌËÚÂ Ò Ñèçè ‚ Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎËÚÂ. àåä ̇ ÇëÄ (ãÇëÄ, ÑÇëÄ Ë Ò‰ÂÌ) ÍÓÂÎË‡ Á̇˜ËÏÓ Ò˙Ò ÒÚÓÈÌÓÒÚËÚ ̇ ıÓÎÂÒÚÂÓ· Ë ÚË„ÎˈÂˉËÚ ÔË ·ÓÎÌËÚÂ Ò ‰Ë‡·ÂÚ̇ Ì‚ÓÔ‡ÚËfl. ÑÓ͇Á‚‡ÌÂÚÓ Ì‡ ‡ÌÌË ‡ÚÂÓÒÍÎÂÓÚ˘ÌË ÔÓÏÂÌË Ì‡ ͇ÓÚˉÌËÚ ‡ÚÂËË ÔË ·ÓÎÌË Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ò˙Á‰‡‚‡ ‚˙ÁÏÓÊÌÓÒÚ Á‡ ÔÓ‚Âʉ‡Ì ̇ ‡Ì̇ ÔÓÙË·ÍÚË͇ ̇ ÏÓÁ˙˜ÌËÚ ËÌÒÛÎÚË ÔË ÚÂÁË ·ÓÎÌË. äãûóéÇà Ñìåà: ‡ÚÂÓÒÍÎÂÓÚ˘ÌË Ô·ÍË, ‰Ë‡·ÂÚ̇ Ì‚ÓÔ‡ÚËfl, ‰ÛÔÎÂÍÒ-ÒÍÂÌË‡ÌÂ, ËÌÚËχ-ωˇ ÍÓÏÔÎÂÍÒ, Ò˙ÌÌË ‡ÚÂËË. äÎËÌËÍÓ-ÂÔˉÂÏËÓÎӄ˘ÌË Ë ÔÓÔÛ·ˆËÓÌÌË ÔÓÛ˜‚‡ÌËfl Ò‡ ÔÓ͇Á‡ÎË ÓÎflÚ‡ ̇ Á‡ı‡ÌËflÚ ‰Ë‡·ÂÚ Í‡ÚÓ ÌÂÁ‡‚ËÒËÏ ËÒÍÓ‚ Ù‡ÍÚÓ Á‡ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚‡ ·ÓÎÂÒÚ, Ô‰ËÏÌÓ Á‡ ÏÓÁ˙˜ÌË ËÌÙ‡ÍÚË (6). éÚÍÓfl‚‡ Ò ÔÓ-„ÓÎflχ ˜ÂÒÚÓÚ‡ ̇ ÏÓÁ˙˜ÌÓ-Ò˙‰Ó‚ËÚ Á‡·ÓÎfl‚‡ÌËfl ÔË ·ÓÎÌËÚ Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÚËÔ II, ÍÓËÚÓ Ò‡ Ò Ôӂ˯ÂÌ ËÒÍ ÓÚ ‡Á‚ËË ̇ ‡ÚÂÓÒÍÎÂÓÁ‡ Ë Ì‡ ÛÒÎÓÊÌÂÌËfl ÔÓ ÚËÔ‡ ̇ ‰Ë‡·ÂÚ̇ ‡Ì„ËÓÔ‡ÚËfl. èÓÒ‰ÒÚ‚ÓÏ ÛÎÚ‡Á‚ÛÍÓ‚Ó ‰ÛÔÎÂÍÒ – ÒÍÂÌË‡Ì ̇ ͇ÓÚˉÌËÚ ‡ÚÂËË ÔË ‡ÒËÏÔÚÓÏÌË Á‡ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚‡ ·ÓÎÂÒÚ Ô‡ˆËÂÌÚË Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Â ÛÒÚ‡ÌÓ‚Â̇ ‡Á΢̇ ˜ÂÒÚÓÚ‡ ̇ ͇ÓÚˉÌË ÒÚÂÌÓÁË, ÍÓflÚÓ ‚‡Ë‡ ÓÚ 18,2% ‰Ó 68,3% (3, 9, 14). èË ·ÓÎÌË Ò ÏÓÁ˙˜ÌË ËÌÙ‡ÍÚË Ë Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ú‡ÁË ˜ÂÒÚÓÚ‡  60% (8). èÂÁ ÔÓÒΉÌËÚ „Ó‰ËÌË ‚ÌËχÌËÂÚÓ Ò ̇ÒÓ˜Ë Í˙Ï ÓÔ‰ÂÎflÌ ̇ ‰Â·ÂÎË̇ڇ ̇ Ò˙‰Ó‚ËÚ ÒÚÂÌË Ì‡ ͇ÓÚˉÌËÚ ‡ÚÂËË Í‡ÚÓ ‡ÌÂÌ ·Â΄ ̇ ͇ÓÚˉ̇ ‡ÚÂÓÒÍÎÂÓÁ‡ Ë ËÒÍÓ‚ Ù‡ÍÚÓ Á‡ ‡Á‚ËÚË ̇ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ (2). àÁÏÂ‚‡ÌÂÚÓ Ì‡ ËÌÚËχ – ωˇ ÍÓÏÔÎÂÍÒ‡ (àåí)

85

̇ Ò˙ÌÌËÚ ‡ÚÂËË ÔÓ͇Á‡ Á̇˜ËÏÓ Ôӂ˯ÂÌË ̇ ÒÚÓÈÌÓÒÚËÚ ÏÛ ÔË ·ÓÎÌË Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÚËÔ II (1, 4, 7, 17, 20). ë‡‚ÌËÚÂÎÌËÚ ÔÓÛ˜‚‡ÌËfl ̇ ‰ˈ‡ ‡‚ÚÓË ÔÓ͇Á‚‡Ú ‡Á΢ÌË ÍÓ·ˆËË Ì‡ àåä Ò ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚÚ‡ ̇ ‰Ë‡·ÂÚ‡ Ë Ì‡Î˘ËÂÚÓ Ì‡ ÌflÍÓË ÌÂ„Ó‚Ë ÛÒÎÓÊÌÂÌËfl ͇ÚÓ ‡Î·ÛÏËÌÛËfl Ë ‰Ë‡·ÂÚ̇ ÂÚËÌÓÔ‡ÚËfl, Ò˙Ò ÒÚÓÈÌÓÒÚËÚ ̇ HbA1c, Í˙‚̇ڇ Á‡ı‡ ̇ „·‰ÌÓ Ë ÓÒÓ·ÂÌÓ Ì‡ ‚ÚÓËfl ˜‡Ò ÒΉ Ó·ÂÏÂÌfl‚‡ÌÂ Ò „βÍÓÁ‡, ͇ÍÚÓ Ë Ò˙Ò ÒÚÓÈÌÓÒÚËÚ ̇ ÒÂÛÏÌËfl ËÌÒÛÎËÌ, ̇ ËÌÒÛÎËÌÓÔÓ‰Ó·ÌËfl ‡ÒÚÂÊÂÌ Ù‡ÍÚÓ Ë Ò Ì‡Î˘Ë ̇ ΘÂÌËÂ Ò ËÌÒÛÎËÌ (1, 6, 10, 11, 12, 13, 14, 15, 18, 21). Ç ÔÓ-ÌÓ‚Ë ËÁÒΉ‚‡ÌËfl Ò‡ ÓÔËÒ‡ÌË Á‡‚ËÒËÏÓÒÚË Ì‡ àåä Ò ‡Á΢ÌË ËÒÍÓ‚Ë Ù‡ÍÚÓË Á‡ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚‡ ·ÓÎÂÒÚ (1, 4, 7, 12, 13, 15, 19 20) ñÂÎÚ‡ ̇ ÔÓÛ˜‚‡ÌÂÚÓ Â ÔÓÒ‰ÒÚ‚ÓÏ ‰ÛÔÎÂÍÒ – ÒÍÂÌË‡Ì ̇ χ„ËÒÚ‡ÎÌËÚ ‡ÚÂËË Ì‡ „·‚‡Ú‡ ‰‡ Ò ÔÓÚ˙ÒflÚ ‰‡ÌÌË Á‡ ‡ÚÂÓÒÍÎÂÓÚ˘ÌË ÔÓÏÂÌË Ì‡ ͇ÓÚˉÌËÚ ‡ÚÂËË ÔË ·ÓÎÌË Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ë ‰Ë‡·ÂÚ̇ Ì‚ÓÔ‡ÚËfl, ͇ÍÚÓ Ë ÚÂıÌË ÍÓ·ˆËË Ò ‰Û„Ë ËÒÍÓ‚Ë Ù‡ÍÚÓË Á‡ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚‡ ·ÓÎÂÒÚ. äéçíàçÉÖçí à åÖíéÑà àÁÒΉ‚‡ÌË Ò‡ 28 ·ÓÎÌË (18 ÊÂÌË Ë 10 Ï˙Ê ̇ Ò‰̇ ‚˙Á‡ÒÚ 63,6 ± 8,7 „Ó‰ËÌË). Ñ‚‡‰ÂÒÂÚ Ë ÔÂÚ ÓÚ ·ÓÎÌËÚ ҇ Ò ‰Ó͇Á‡Ì Á‡ı‡ÂÌ ‰Ë‡·ÂÚ 2 ÚËÔ Ë ÚËχ ·ÓÎÌË Ò 1 ÚËÔ. èÓ‰˙ÎÊËÚÂÎÌÓÒÚÚ‡ ̇ Á‡ı‡ÌËfl ‰Ë‡·ÂÚ Â ÓÚ 2 ‰Ó 30 „Ó‰ËÌË, Ò‰ÌÓ 13,14 ± 7,7 „Ó‰ËÌË. èË ÔÓ-„ÓÎflχ ˜‡ÒÚ ÓÚ ·ÓÎÌËÚ Ò ÔÓ‚Âʉ‡ ΘÂÌËÂ Ò Ó‡ÎÌË ‡ÌÚˉˇ·ÂÚÌË Ò‰ÒÚ‚‡, ‡ 7 ÓÚ Úflı (25%) Ò‡ ̇ ΘÂÌËÂ Ò ËÌÒÛÎËÌ. ÇÒ˘ÍË ·ÓÎÌË Ò‡ Ò ‰Ë‡·ÂÚ̇ ÔÓÎËÌ‚ÓÔ‡ÚËfl ̇ ‰ÓÎÌËÚ Í‡ÈÌËˆË (Ñèçè), Ò˙˜Âڇ̇ ÔË 6 ÓÚ Úflı Ò ‡‚ÚÓÌÓÏ̇ Ì‚ÓÔ‡ÚËfl. Ñˇ„ÌÓÁ‡Ú‡ ̇ Ñèçè  ÔÓÚ‚˙‰Â̇ Ò ÂÎÂÍÚÓÌ‚Ó„‡ÙËfl , ÍÓflÚÓ ÔÓ͇Á‚‡ ÔÂӷ·‰‡‚‡˘Ó Ò‰ÌÓ Í˙Ï ÚÂÊÍÓ Û‚Âʉ‡Ì ̇ ÒÂÚË‚ÌËÚÂ Ë ‰‚Ë„‡ÚÂÎÌËÚ ‚·Í̇ ̇ ÔÂËÙÂÌËÚ ÌÂ‚Ë Ë ÔÓ-fl‰ÍÓ Ò‡ÏÓ Ì‡ ÒÂÚË‚ÌËÚ ‚·Í̇.Ñ‚‡‰ÂÒÂÚ Ë ÚËχ ·ÓÎÌË (82,1%) Ò‡ Ò ÔˉÛʇ‚‡˘‡ ‡ÚÂˇÎ̇ ıËÔÂÚÓÌËfl. èË ·ÓÎÌËÚ  Ôӂ‰ÂÌÓ ÔÓ‰Ó·ÌÓ ÍÎËÌ˘ÌÓ ËÁÒΉ‚‡ÌÂ, ÍÓÂÚÓ ‚Íβ˜‚‡ ÒÓχÚ˘ÂÌ Ë Ì‚ÓÎӄ˘ÂÌ ÒÚ‡ÚÛÒ, ‚˙ÔÓÒÌËÍ Á‡ ËÒÍÓ‚Ë Ù‡ÍÚÓË Á‡ ÏÓÁ˙˜ÌÓÒ˙‰Ó‚‡ ·ÓÎÂÒÚ, Í˙‚ÌÓÁ‡ı‡ÂÌ ÔÓÙËÎ. ê„ËÒÚË‡ÌË Ò‡ ÒÚÓÈÌÓÒÚËÚ ̇ ÒËÒÚÓÎÌÓÚÓ (ëÄç) Ë ‰Ë‡ÒÚÓÎÌÓÚÓ (ÑÄç) ‡ÚÂˇÎÌÓ Ì‡Îfl„‡Ì ÔÓ Ï‡Ì¯ÂÚÌËfl ÒÔÓÒÓ· Ë Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ (ëó). ë‰ÌÓÚÓ ‡ÚÂˇÎÌÓ Ì‡Îfl„‡Ì (ëÄç)  ËÁ˜ËÒÎfl‚‡ÌÓ ÔÓ ÙÓÏÛ·ڇ ̇ Wiggers. àÁÏÂ‚‡ÌË Ò‡ ˙ÒÚ‡ (m) Ë ÚÂÎÂÒÌÓÚÓ Ú„ÎÓ (kg) Ë Â ËÁ˜ËÒÎfl‚‡Ì Ë̉ÂÍÒ˙Ú Ì‡ ÚÂÎÂÒ̇ χ҇ (BMI) ‚ kg/m2(Ú‡·Î.1). 凄ËÒÚ‡ÎÌËÚ ‡ÚÂËË Ì‡ „·‚‡Ú‡ Ò‡ ÓˆÂÌfl‚‡ÌË Ò ˆ‚ÂÚÌÓ ‰ÛÔÎÂÍÒ-ÒÍÂÌË‡Ì ÔË ËÁÔÓÎÁ‚‡Ì ̇ 5 MHz ÒÓ̉‡ Ò ‡Ô‡‡Ú‡ VersaPlus ̇ ÙËχڇ Siemens. óÂÁ Ç-ÒÍÂÌË‡Ì ‚˙ıÛ ÙËÍÒË‡Ì Ó·‡Á  ËÁÏÂ‚‡Ì ‰Ë‡ÏÂÚ˙‡ ̇ ÎÛÏÂ̇ ̇ Ó·˘‡Ú‡ Ò˙Ì̇ (éëÄ), ‚˙Ú¯̇ڇ Ò˙Ì̇ (ÇëÄ) Ë ‚ÂÚ·‡ÎÌËÚ (ÇÄ) ‡ÚÂËË ‚ ̇‰Î˙ÊÂÌ ‡ÁÏÂ ͇ÚÓ ‡ÁÒÚÓflÌË ÏÂÊ‰Û ËÌÚËχڇ ̇ Ò˙‰Ó‚ËÚe ÒÚÂÌË. Ñ·ÂÎË̇ڇ ̇ Ò˙‰Ó‚‡Ú‡ ÒÚÂ̇  ËÁÏÂÂ̇ ‚ mm ˜ÂÁ ÓˆÂÌ͇ ̇ ËÌÚËχ-ωËfl ÍÓÏÔÎÂÍÒ‡ /àåä/ ̇ ÔÓ-ÓÚ‰‡Î˜Â̇ڇ ÓÚ ÒÓ̉‡Ú‡ ÒÚÂ̇. óÂÁ ËÁÔÓÎÁ‚‡Ì ̇ å-mode ËÁÓ·‡Áfl‚‡Ì  ËÁÏÂÂÌ ‰Ë‡ÏÂÚ˙‡ ̇ éëÄ Ë ÇëÄ ÔÓÓÚ‰ÂÎÌÓ ‚ ÒËÒÚÓ· Ë ‰Ë‡ÒÚÓ·. ë ‰ÓÔÎÂÓ‚‡ ÒÓÌÓ„‡ÙËfl Ò‡ ÓÔ‰ÂÎflÌË ÒËÒÚÓÎ̇ڇ (ëë), Ò‰̇ڇ (ëë) Ë ‰Ë‡ÒÚÓÎ̇ڇ (Ñë) ÒÍÓÓÒÚË Ì‡ Í˙‚ÌËfl ÚÓÍ ÔË ‡ÁÔÓÎÓÊÂÌË ̇ ÔÓ·ÌËfl Ó·ÂÏ ‚ ˆÂÌÚ˙‡ ̇ Ò˙‰‡ Ë ÔË ˙„˙Π̇ ËÌÒÓÌË‡Ì ÓÚ 45%. ᇠéëÄ ËÁÏÂ‚‡ÌËflÚ‡ Ò‡ Ôӂ‰ÂÌË Ì‡ 1 cm ÔÓÍÒËχÎÌÓ ÓÚ ·ËÙÛ͇ˆËflÚ‡, ‡ Á‡ ÇëÄ - ÌÂÔÓÒ‰ÒÚ‚ÂÌÓ ÒΉ bulbus caroticus. ëÚÂÔÂÌÚ‡ ̇ ÒÚÂÌÓÁËÚ  ÓÔ‰ÂÎfl̇ ÔÓÒ‰ÒÚ‚ÓÏ ÏÓÙÓÎӄ˘ÌËfl ÏÂÚÓ‰ ‚ ̇Ô˜ÂÌ ÒÂÁ ̇ ËÁÒΉ‚‡ÌËfl Í˙‚ÓÌÓÒÂÌ Ò˙‰. í ҇ ͇Ú„ÓË-


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

ÁË‡ÌË Í‡ÚÓ: ÌËÒÍÓÒÚÂÔÂÌÌË (‰Ó 49%), Ò‰ÌÓÒÚÂÔÂÌÌË (50-69%), ‚ËÒÓÍÓÒÚÂÔÂÌÌË ÒÚÂÌÓÁË (70-99%) Ë ÚÓÏ·ÓÁË. åÓÙÓÎÓ„ËflÚ‡ ̇ Ô·ÍËÚ  ӈÂÌfl‚‡Ì‡ ÔÓ Úflı̇ڇ ÂıÓ„ÂÌÌÓÒÚ (‡ÌÂıÓ„ÂÌÌË, ËÁÓÂıÓ„ÂÌÌË, ıËÔÂÂıÓ„ÂÌÌË) Ë ÍÓÌÒËÒÚÂ̈Ëfl (ıÓÏÓ„ÂÌÌË, ıÂÚÂÓ„ÂÌÌË, ÒÏÂÒÂÌË Ë Í‡ÎˆË‡ÌË), ‡ ÔÓ‚˙ıÌÓÒÚÚ‡ ËÏ Â ÓˆÂÌfl‚‡Ì‡ ͇ÚÓ „·‰Í‡ , ÌÂ‡‚̇ ËÎË ÍÛıËÌ̇. Ç ÍÎËÌ˘ÂÌ ‡ÒÔÂÍÚ Ô·ÍËÚ ҇ ı‡‡ÍÚÂËÁË‡ÌË Í‡ÚÓ ÒÚ‡·ËÎÌË Ë ÌÂÒÚ‡·ËÎÌË. éÚ˜ËÚ‡ÌË Ò‡ Ô‡ÚÓÎӄ˘ÌËÚ ËÁ‚Ë‚ÍË Ì‡ Ò˙ÌÌËÚ ‡ÚÂËË, ̇΢ËÂÚÓ Ì‡ ·ËÏÍË Ë ıËÔÓÔ·ÁËfl. êÂÁÛÎÚ‡ÚËÚ ÓÚ ÍÎËÌ˘ÌÓÚÓ Ë ÛÎÚ‡Á‚ÛÍÓ‚ÓÚÓ ËÁÒΉ‚‡Ì ҇ Ò‡‚ÌÂÌË Ò ÚÂÁË Ì‡ ÍÓÌÚÓÎ̇ „ÛÔ‡ ÓÚ 16 ÍÎËÌ˘ÌÓ Á‰‡‚Ë Îˈ‡ ‚ Ò˙˘Ëfl ‚˙Á‡ÒÚÓ‚ ‰Ë‡Ô‡ÁÓÌ. ᇠÒÚ‡ÚËÒÚ˘ÂÒ͇ Ó·‡·ÓÚ͇ ̇ ‰‡ÌÌËÚ  ËÁÔÓÎÁ‚‡Ì ÔÓ„‡ÏÂÌ ÔÓ‰ÛÍÚ (SPSS 10.0 for Windows, SPSS, Chicago, IL). àÁÔÓ΂‡ÌË Ò‡ ‚‡ˇˆËÓÌÂÌ Ë ÌÂÔ‡‡ÏÂÚ˘ÂÌ ÍÓ·ˆËÓÌÂÌ ‡Ì‡ÎËÁ Ò ËÁ˜ËÒÎfl‚‡Ì ̇ ÍÓÂÙˈËÂÌÚ Ì‡ Pearson. èËÂÚÓ Â ÌË‚Ó Ì‡ Á̇˜ËÏÓÒÚ p 0.05. êÖáìãíÄíà ë‡‚ÌËÚÂÎ̇ ı‡‡ÍÚÂËÒÚË͇ ̇ ÓÒÌÓ‚ÌËÚ ÒÓχÚ˘ÌË ÔÓ͇Á‡ÚÂÎË Ì‡ ËÁÒΉ‚‡Ì‡Ú‡ „ÛÔ‡ Ò ‰Ë‡·ÂÚ̇ ÔÓÎËÌ‚ÓÔ‡ÚËfl  Ô‰ÒÚ‡‚Â̇ ̇ Ú‡·Îˈ‡ 1. Ç Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎËÚ ·ÓÎÌËÚÂ Ò Ñèçè Ò‡ Ò Ì‡‰ÌÓÏÂÌÓ Ú„ÎÓ Ë ËÏ‡Ú ÔÓ-‚ËÒÓÍË ÒÚÓÈÌÓÒÚË Ì‡ ‡ÚÂˇÎÌÓÚÓ Ì‡Îfl„‡ÌÂ. ë‰ÌËÚ ÒÚÓÈÌÓÒÚË Ì‡ ÒÛÚ¯̇ڇ Í˙‚̇ Á‡ı‡ ̇ 퇷Îˈ‡ 1. äÎËÌ˘̇ ı‡‡ÍÚÂËÒÚË͇ ̇ ·ÓÎÌËÚÂ Ò ‰Ë‡·ÂÚ̇ ÔÓÎËÌ‚ÓÔ‡ÚËfl Ë ÍÓÌÚÓÎËÚ ·ÓÈ Ò. ‚˙Á‡ÒÚ ‚ËÒÓ˜Ë̇ Ú„ÎÓ BMI ëÄç ÑÄç ëÄç

äÓÌÚÓÎË 16 51.7±10 1.67±0.07 68.3±10.5 24.5±3.7 125±22 75±9 92±12

Ñèçè 28 63.6±8.7 1.69±0.07 79.2±14 27.9±4.7* 140±13* 85±8*** 101±13*

„·‰ÌÓ ÔË ·ÓÎÌËÚ ҇ 8,34±3,22mmol/l, ̇ ıÓÎÂÒÚÂÓ· 6,47±1,25mmol/l, ‡ ̇ ÚË„ÎˈÂˉËÚ – 2,28±1,17mmol/l. á‰‡‚ËÚ Îˈ‡ ËÏ‡Ú ÌÓχÎ̇ ÒÓÌÓ„‡Ù̇ ̇ıӉ͇ ̇ Ò˙ÌÌËÚÂ Ë ‚ÂÚ·‡ÎÌËÚ ‡ÚÂËË. èË ·ÓÎÌËÚ Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ë ‰Ë‡·ÂÚ̇ ÔÓÎËÌ‚ÓÔ‡ÚËfl ÔÂӷ·‰‡‚‡Ú ıÂÚÂÓ„ÂÌÌË ‡ÚÂÓÒÍÎÂÓÚ˘ÌËÚ Ô·ÍË ‚˙‚ ÇëÄ, ‚Ó‰Â˘Ë ‰Ó ÌËÒÍÓÒÚÂÔÂÌÌË ÒÚÂÌÓÁË ÓÚ 10% ‰Ó 25%.í Ò Ò¢‡Ú ÔË 9 ·ÓÎÌË ‚ ãÇëÄ, ÔË 12 ·ÓÎÌË ‚ ÑÇëÄ Ë ÔË 7 ·ÓÎÌË ‰‚ÛÒÚ‡ÌÌÓ. èË 1 ·ÓÎÂÌ Â Ì‡ÏÂÂ̇ ÚÓÏ·ÓÁ‡ ̇ ãÇëÄ. Ç éëÄ ‰‚ÛÒÚ‡ÌÌË ÌËÒÍÓÒÚÂÔÂÌÌË ÒÚÂÌÓÁË Ò‡ ̇·Î˛‰‡‚‡ÌË ÔË 2 ·ÓÎÌË. ïÂÚÂÓ„ÂÌÌË Ô·ÍË, ÒÚÂÌÓÁË‡˘Ë ÎÛÏÂ̇ ̇ Ò˙‰‡ ÏÂÊ‰Û 25 Ë 49% Ò‡ ÛÒÚ‡ÌÓ‚ÂÌË ÔË 2 ·ÓÎÌË ‚ ãéëÄ, ‡ ÔË 1 ·ÓÎÂÌ ‚ ÑéëÄ. ë‰ÌËÚ ÒÚÓÈÌÓÒÚË Ë Òڇ̉‡ÚÌËÚ ÓÚÍÎÓÌÂÌËfl ̇ ÒÓÌÓ„‡ÙÌËÚ ÔÓ͇Á‡ÚÂÎË Ì‡ χ„ËÒÚ‡ÎÌËÚ ‡ÚÂËË Ì‡ „·‚‡Ú‡ ÔË ·ÓÎÌËÚÂ Ë ÍÓÌÚÓÎËÚ ҇ Ô‰ÒÚ‡‚ÂÌË Ì‡ Ú‡·Îˈ‡ 2. èË ·ÓÎÌËÚÂ Ò Ñèçè ‰Ë‡ÏÂÚ˙‡ ̇ Ò˙ÌÌËÚ ‡ÚÂËË Ò ۂÂ΢‡‚‡, ͇ÚÓ Û‚Â΢ÂÌËÂÚÓ Â Á̇˜ËÏÓ Ì ‰ÂÒÌËÚ Ò˙ÌÌË ‡ÚÂËË – ÑéëÄ Ë ÑÇëÄ. Ç ÚÂÁË ‡ÚÂËË Ò ̇·Î˛‰‡‚‡ ÚẨÂ̈Ëfl Í˙Ï Ì‡Ï‡ÎÂÌË ̇ ÒÍÓÓÒÚÌËÚ ԇ‡ÏÂÚË. àÁÏÂ‚‡ÌÂÚÓ Ì‡ àåä ÔÓ͇Á‡‚‡ Á̇˜ËÏÓ Á‡‰Â·ÂÎfl‚‡Ì ̇ Ò˙‰Ó‚ËÚ ÒÚÂÌË ÔË ·ÓÎÌËÚÂ Ò Ñèçè ‚ Ò‡‚ÌÂÌËÂ Ò ÍÓÌÚÓÎËÚÂ, ÍÓÂÚÓ ‰ÓÒÚË„‡ ÒÚ‡ÚËÒÚ˘̇ Á̇˜ËÏÓÒÚ ‚ ‰‚ÂÚ éëÄ Ë ‚ ÑÇëÄ. ç‡ÏÂÂÌË Ò‡ Á̇˜ËÏË ÍÓ·ˆËË Ì‡ àåä ̇ ÇëÄ

86

(ãÇëÄ, ÑÇëÄ Ë Ò‰ÂÌ) Ò˙Ò ÒÚÓÈÌÓÒÚË Ì‡ ıÓÎÂÒÚÂÓ· Ë ÚË„ÎˈÂˉËÚ ÔË ·ÓÎÌËÚÂ Ò ‰Ë‡·ÂÚ̇ Ì‚ÓÔ‡ÚËfl. äÓÂÙˈËÂÌÚËÚ ̇ ÍÓ·ˆËfl ̇ àåä ̇ ãÇëÄ Ë ÑÇëÄ Ò ıÓÎÂÒÚÂÓ· Ë ÚË„ÎˈÂˉËÚ ËÏ‡Ú Â‰Ì‡Í‚‡ ÒÚÓÈÌÓÒÚ (r=0,40, p< 0,05).ç‡È-‚ËÒÓÍË Ò‡ ÍÓ·ˆËËÚ ̇ Ò‰ÌËfl àåä Ò ıÓÎÂÒÚÂÓ· (r = 0,50, p< 0,01) Ë Ò ÚË„ÎˈÂˉËÚ (r = 0,50, p< 0,01). 퇷Îˈ‡ 2. ëÓÌÓ„‡ÙÌË ÔÓ͇Á‡ÚÂÎË Ì‡ ·ÓÎÌËÚÂ Ò Ñèçè Ë ÍÓÌÚÓÎËÚÂ

ãéëÄ ÑˇÏÂÚ˙ ÒËÒÚÓ· (mm) ÑˇÏÂÚ˙ ‰Ë‡ÒÚÓ· (mm) àåä (mm) ëë (cm/s) ëë (cm/s) Ñë (cm/s) ÑéëÄ ÑˇÏÂÚ˙ ÒËÒÚÓ· (mm) ÑˇÏÂÚ˙ ‰Ë‡ÒÚÓ· (mm) àåä (mm) ëë (cm/s) ëë (cm/s) Ñë (cm/s) ãÇëÄ ÑˇÏÂÚ˙ ÒËÒÚÓ· (mm) ÑˇÏÂÚ˙ ‰Ë‡ÒÚÓ· (mm) àåä (mm) ëë (cm/s) ëë (cm/s) Ñë (cm/s) ÑÇëÄ ÑˇÏÂÚ˙ ÒËÒÚÓ· (mm) ÑˇÏÂÚ˙ ‰Ë‡ÒÚÓ· (mm) àåä (mm) ëë (cm/s) ëë (cm/s) Ñë (cm/s) ãÇÄ ÑˇÏÂÚ˙ (mm) ëë (cm/s) ëë (cm/s) Ñë (cm/s) ÑÇÄ ÑˇÏÂÚ˙ (mm) ëë (cm/s) ëë (cm/s) Ñë (cm/s) Ë̉ÂÍÒË ãéëÄ/ãÇëÄ ÑéëÄ/ÑÇëÄ * p < 0,05 *** p < 0,001

äÓÌÚÓÎË 16 5.79±0.84 5.47±0.84 0.55±0.08 66±36 35±18 20±11 5.95±0.89 5.46±0.99 0.51±0.11 61±28 34±16 20±9 5.08±0.92 4.77±0.96 0.49±0.11 64±18 40±10 27±7 4.96±0.87 4.6±0.90 0.48±0.09 63±20 40±12 28±11 3.40±0.46 36±18 22±10 14±7 3.15±0.49 33±16 20±11 12±6 1.16±0.13 1.23±0.14

Ñèçè 28 6.65±0.86 5.96±0.91 1.08±0.23*** 54±23 26±10 14±6 6.67±0.72* 6.08±0.73* 1.03±0.21*** 53±20 26±9 16±11 5.49±0.89 4.94±0.94 0.88±0.15 70±23 39±12 23±9 5.65±0.98* 5.00±0.95 0.94±0.15*** 67±15 37±10 22±8 3.26±0.45 39±16 23±10 12±6 3.08±0.49 33±10 18±5 11±3 1.00±0.11 1.20±0.17

éÅëöÜÑÄçÖ ÑÓ· ËÁ‚ÂÒÚ̇  ÓÎflÚ‡ ̇ Á‡ı‡ÌËfl ‰Ë‡·ÂÚ Á‡ ‚˙ÁÌËÍ‚‡Ì ̇ ̇Û¯ÂÌËfl ̇ ÏËÍÓˆËÍÛ·ˆËflÚ‡. ë ‰Ó͇Á‚‡ÌÂÚÓ Ì‡ àåä ͇ÚÓ ‡ÌÂÌ ·Â΄ ̇ ‡ÚÂÓÒÍÎÂÓÁ‡ ̇ ͇ÓÚˉÌËÚ ‡ÚÂËË Ò ÔÓÚ‚˙‰Ë Á̇˜ÂÌËÂÚÓ ÏÛ Á‡ flÁ‚ËÚË ̇ χÍÓ‚‡ÒÍÛ·ÌËÚ ÛÒÎÓÊÌÂÌËfl. êÂÁÛÎÚ‡ÚËÚ ÓÚ Ì‡¯ÂÚÓ ÔÓÛ˜‚‡ÌÂ Ò ‰ÛÔÎÂÍÒ-ÒÍÂÌË‡Ì ̇ Ò˙ÌÌËÚ ‡ÚÂËË ÔË ·ÓÎÌË Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ë ‰Ë‡·ÂÚ̇ Ì‚ÓÔ‡ÚËfl Ò˙‚Ô‡‰‡Ú Ò ‰‡ÌÌËÚ ̇ ‰Û„Ë ‡‚ÚÓË, ÍÓËÚÓ Ì‡ÏË‡Ú Á‡‰Â·ÂÎfl‚‡Ì ̇ Ò˙‰Ó‚ËÚ ËÏ ÒÚÂÌË Í‡ÚÓ ‡ÌÂÌ ·Â΄ ̇ ͇ÓÚˉ̇ ‡ÚÂÓÒÍÎÂÓÁ‡ (1, 4, 7, 17, 20). 燷≇‚‡ÌË Ò‡ ÍÓ·ˆËË Ì‡ àåä Ò ‚˙Á‡ÒÚÚ‡, ÔÓ·, ÒÂÛÏÌËÚ ÎËÔˉË, ̇΢ËÂÚÓ Ì‡ ‡ÚÂˇÎ̇ ıËÔÂÚÓÌËfl Ë ÔÛÎÒÓ‚ÓÚÓ Ì‡Îfl„‡Ì ÔË ·ÓÎÌËÚ Ò˙Ò Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÚËÔ 2, (1, 4, 7, 12, 13,15, 19, 20) Ë Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÚËÔ1.(5, 16).. èÓÛ˜‚‡ÌËflÚ‡ Ò‡ ÔÓ͇Á‡ÎË Ôӂ˯ÂÌË ̇ àåä Ò Ì‡Ô‰‚‡Ì ̇ ‚˙Á‡ÒÚÚ‡ (1, 4, 7, 15, 19), ÔË Ì‡Î˘Ë ̇ ÔˉÛʇ‚‡˘‡ ‡ÚÂˇÎ̇ ıËÔÂÚÓÌËfl (1, 7, 18, 20), ̇ „ÂÌÂÚ˘ÌË ËÒÍÓ‚Ë Ù‡ÍÚÓË Á‡ ͇ÓÚˉ̇ ‡ÚÂÓ-


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

ÒÍÎÂÓÒÍÎÂÓÁ‡ (22) Ë Ì‡ Ôӂ˯ÂÌË ÒÂÛÏÌË ÎËÔË‰Ë (4, 7, 13, 20). Ç˙Á‡ÒÚÚ‡ Ë Ôӂ˯ÂÌËÚ ÒÂÛÏÌË ÎËÔË‰Ë Ò ÓÚÍÓfl‚‡Ú Ò‰ ËÒÍÓ‚ËÚ هÍÚÓË Á‡ ͇ÓÚˉ̇ ‡ÚÂÓÒÍÎÂÓÁ‡. èË Ì‡¯ËÚ ·ÓÎÌË àåä ÍÓÂÎË‡ Á̇˜ËÏÓ Ò‡ÏÓ Ò˙Ò ÒÂÛÏÌËÚ ÎËÔˉË, ‡ ÓÚÒ˙ÒÚ‚ËÂÚÓ Ì‡ ‰Û„Ë ÍÓ·ˆËË ‚ÂÓflÚÌÓ Ò ‰˙ÎÊË Ì‡ Ò‡‚ÌËÚÂÎÌÓ Ï‡ÎÍËfl ·ÓÈ Ì‡ ËÁÒΉ‚‡ÌËÚ ԇˆËÂÌÚË. Ç Á‡Íβ˜ÂÌËÂ, ÔÓÛ˜‚‡ÌÂÚÓ ÔÓÒ‰ÒÚ‚ÓÏ ‰ÛÔÎÂÍÒ-ÒÍÂÌË‡Ì ̇ Ò˙ÌÌËÚ ‡ÚÂËË ÔË ·ÓÎÌË Ò˙Ò áÑ Ë Ñèçè ÔÓ͇Á‚‡ ̇΢ˠ̇ ‡ÌÌË ‡ÚÂÓÒÍÎÂÓÚ˘ÌË ÔÓÏÂÌË ‚ ÚÂÁË ‡ÚÂËË. éÒÓ·ÂÌÓ ÔÓ͇Á‡ÚÂÎÌÓ Â Á̇˜ËÏÓÚÓ Ôӂ˯ÂÌË ̇ àåä. 燂ÂÏÂÌÌÓÚÓ ÓÚÍË‚‡Ì ̇ ÚÂÁË ÔÓÏÂÌË Ò˙Á‰‡‚‡ ‚˙ÁÏÓÊÌÓÒÚË Á‡ ÔÓ‚Âʉ‡Ì ̇ ‡Ì̇ ÔÓÙË·ÍÚË͇ ̇ ÏÓÁ˙˜ÌËÚ ËÌÒÛÎÚË. ãàíÖêÄíìêÄ 1.

2.

3.

4.

5. 6.

7.

8. 9.

Bonora E, Tessari R, Micciolo R, Zenere M, Targher G, Padovani R, Falezza G, Muggeo M. Intimal-medial thickness of the carotid artery in nondiabetic and NIDDM patients. Relationship with insulin resistance. Diabetes Care. 20, 1997, 4, 627-31. Chambless, LE; Folsom, AR, Clegg, L., Sharrett, AR, Shahar, E., Nieto, F.; Rosamond, W. D., Evans, G., Carotid wall thickness is predictive of incident clinical stroke: The atherosclerosis risk in communities (ARIC) study. American Journal of Epidemiology. 151, 2000.,5, 478-487. De Angelis M, Scrucca L, Leandri M, Mincigrucci S, Bistoni S, Bovi M, Calabrese G, Pippi R, Parretti D, Grilli P, Colorio P, Fattorini M, Flamini O, Pacetti E, Travaglini A, Santeusanio F. Prevalence of carotid stenosis in type 2 diabetic patients asymptomatic for cerebrovascular disease. Diabetes Nutr Metab. 16, 2003, 1, 48-55. de Vries R, Dallinga-Thie GM, Smit AJ, Wolffenbuttel BH, van Tol A, Dullaart RP. Elevated plasma phospholipid transfer protein activity is a determinant of carotid intima-media thickness in type 2 diabetes mellitus. Diabetologia. 49, 2006, 2, 398-404. Distiller LA, Joffe BI, Melville V, Welman T, Distiller GB. Carotid artery intima-media complex thickening in patients with relatively long-surviving type 1 diabetes mellitus. J Diabetes Complications. 20, 2006, 5, 280-284. Folsom AR, Eckfeldt JH, Weitzman S, Ma J, Chambless LE, Barnes RW, Cram KB, Hutchinson RG. Relation of carotid artery wall thickness to diabetes mellitus, fasting glucose and insulin, body size, and physical activity. Atherosclerosis Risk in Communities (ARIC) Study Investigators. Stroke, 25, 1994, 66-73. Frost D, Frohlich B, Beischer W. Subclinical arteriosclerosis in patients with newly diagnosed type 2 diabetes mellitus. Demonstration by high-resolution ultrasound measurements of intima-media thickness of the common carotid and femoral arteries. Dtsch Med Wochenschr. 125, 2000, 21, 648-654. Fulesdi B, Bereczki D, Mihalka L, Fekete I, Siro P, Leanyvari Z, Valikovics A, Csiba L. Carotid atherosclerotic lesions in stroke patients with diabetes mellitus. Orv Hetil. 140, 1999, 13, 697-700. Fukuhara T, Hida K. Pulsatility index at the cervical internal carotid artery as

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a parameter of microangiopathy in patients with type 2 diabetes. J Ultrasound Med. 25, 2006, 5, 599-605. 10. Hanefeld M, Koehler C, Henkel E, Fuecker K, Schaper F, TemelkovaKurktschiev T. Post-challenge hyperglycaemia relates more strongly than fasting hyperglycaemia with carotid intima-media thickness: the RIAD Study. Risk Factors in Impaired Glucose Tolerance for Atherosclerosis and Diabetes. Diabet Med. 17, 2000, 12, 835-840. 11. Hanefeld M, Temelkova-Kurktschiev T, Schaper F, Henkel E, Siegert G, Koehler C. Impaired fasting glucose is not a risk factor for atherosclerosis. Diabet Med. 16, 1999, 3, 212-218. 12. Keech AC, Grieve SM, Patel A, Griffiths K, Skilton M, Watts GF, Marwick TH, Groshens M, Celermajer DS. Urinary albumin levels in the normal range determine arterial wall thickness in adults with Type 2 diabetes: a FIELD substudy. Diabet Med. 22, 2005, 11, 1558-1565. 13. Kim HJ, Ahn CW, Kang ES, Myoung SM, Cha BS, Won YJ, Lim SK, Kim KR, Huh KB, Lee HC. The level of 2-h post-challenge glucose is an independent risk factor of carotid intima-media thickness progression in Korean type 2 diabetic patients. J Diabetes Complications. 21, 2007, 1, 7-12. 14. Lacroix P, Aboyans V, Criqui MH, Bertin F, Bouhamed T, Archambeaud F, Laskar M. Type-2 diabetes and carotid stenosis: a proposal for a screening strategy in asymptomatic patients. Vasc Med. 11, 2006, 2, 93-99. 15. Leinonen ES, Salonen JT, Salonen RM, Koistinen RA, Leinonen PJ, Sarna SS, Taskinen MR. Reduced IGFBP-1 is associated with thickening of the carotid wall in type 2 diabetes. Diabetes Care. 25, 2002, 10, 1807-1812. 16. Makimattila S, Ylitalo K, Schlenzka A, Taskinen MR, Summanen P, Syvanne M, Yki-Jarvinen H. Family histories of Type II diabetes and hypertension predict intima-media thickness in patients with Type I diabetes. Diabetologia. 45, 2002, 5, 711-718. 17. Mudrikova T, Szabova E,Tkac I. Carotid intima-media thickness in relation to macrovascular disease in patients with type 2 diabetes mellitus. Wien Klin Wochenschr. 112, 2000, 20, 887-891. 18. Nathan DM, Lachin J, Cleary P, Orchard T, Brillon DJ, Backlund JY, O'Leary DH, Genuth S. Intensive diabetes therapy and carotid intima-media thickness in type 1 diabetes mellitus. N Engl J Med. 348, 2003, 23, 22942303. 19. Taniguchi A, Nakai Y, Fukushima M, Teramura S, Hayashi R, Hama K, Marumoto K, Watanabe T, Yoshioka I, Sakaguchi K, Kishimoto H, Matsushita K, Okumura T, Tokuyama K, Nagasaka S, Sakai M. Ultrasonographically assessed carotid atherosclerosis in Japanese type 2 diabetic patients: Role of nonesterified fatty acids. Metabolism. 51, 2002, 5, 5395-43. 20. Temelkova-Kurktschiev TS, Koehler C, Henkel E, Hanefeld M. Leukocyte count and fibrinogen are associated with carotid and femoral intima-media thickness in a risk population for diabetes. Cardiovasc Res. 56, 2002, 2, 277-83. 21. Temelkova-Kurktschiev TS, Koehler C., Leonhardt W, Schaper F, Henkel E, Siegert G, Hanefeld M. Increased intimal-medial thickness in newly detected type 2 diabetes: risk factors. Diabetes Care. 22, 1999, 2. 333-338. 22. Yamasaki Y, Katakami N, Sakamoto K, Kaneto H, Matsuhisa M, Sato H, Hori M, Haneda M, Kashiwagi A, Tanaka Y, Kawamori R, Kuno S. Combination of Multiple Genetic Risk Factors Is Synergistically Associated With Carotid Atherosclerosis in Japanese Subjects With Type 2 Diabetes. Diabetes Care 29, 2006, 2445-2451.


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

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éË„Ë̇ÎÌË ÒÚ‡ÚËË íêÄçáàíéêçÄ ÉãéÅÄãçÄ ÄåçÖáàü û. èÂÚÓ‚‡, ã. í‡ÈÍÓ‚, à. í˙Ì‚, å. äÛÔ‚, Å. åË΂ ÄÎÂÍ҇̉Ó‚Ò͇ ·ÓÎÌˈ‡, äÎËÌË͇ ÔÓ ç‚ÓÎÓ„Ëfl, ñÂÌÚ˙ ÔÓ Ó·‡Á̇ ‰Ë‡„ÌÓÒÚË͇ SUMMARY TRANSIENT GLOBAL AMNESIA H. Petrova, L. Trajkov, I. Tarnev, M. Krupev, B. Milev Alexander Hospital – Sofia Center of Imaging Diagnostic Transient global amnesia is a state of immediately and isolated dysfunction of memory for states in a few seconds till few hours without any consciousness loses, without neurological and cardiological changes. To these moments the pathogenesis of the disease is not clear. The most cases in literature concerning to etiology of syndrome are ischemic vascular diseases (TIA, stroke), venous thromboses, epilepsy and migraine. The diagnostic criteria used since 1990 by Hodges, Warlow and Caplan do the syndrome easier and more correctly. Four patients with criteria of these amnesia are studied. Average timing of memory absent is 4 hours. There were a total disorientation for time and place for all of the patients. A MRI has made for all of the patients. The thrombosis of sinus sagitalis superior for three of the patients was found, and the fourth of them was with reduction of blood flow with subtotal thrombosis. Transient global amnesia patients have changes of the venous blood flow and have less cases of intravenous thrombosis signed in literature. The found results are as confirmation of these conclusion. KEY WORDS: amnesia; transient global, venous thrombosis. êÖáûåÖ í‡ÌÁËÚÓ̇ڇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl  Ò˙ÒÚÓflÌË ̇ ‚ÌÂÁ‡Ô̇ Ë ËÁÓÎË‡Ì‡ ‰ËÒÙÛÌ͈Ëfl ̇ Ô‡ÏÂÚÚ‡ Á‡ Ò˙·ËÚËfl ‚ ÔÓ‰˙ÎÊÂÌË ÓÚ ÌflÍÓÎÍÓ ÒÂÍÛÌ‰Ë ‰Ó ÌflÍÓÎÍÓ ˜‡Ò‡ ·ÂÁ ÌË͇͂‡ Á‡„Û·‡ ̇ Ò˙Á̇ÌËÂ, ·ÂÁ ‰‡ÌÌË Á‡ Ì‚ÓÎӄ˘ÌË Ë Í‡‰ËÓÎӄ˘ÌË ÔÓÏÂÌË. è‡ÚÓ„ÂÌÂÁ‡Ú‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ ‰Ó Ò„‡ Ì  ËÁflÒÌÂ̇. èӂ˜ÂÚÓ ÒÎÛ˜‡Ë ÔÛ·ÎËÍÛ‚‡ÌË ‚ ÎËÚÂ‡ÚÛ‡Ú‡, Ò‚˙Á‡ÌË Ò ÂÚËÓÎÓ„ËflÚ‡ ̇ ÒË̉Óχ Ò‡ ËÒıÂÏ˘ÌË Ò˙‰Ó‚Ë Á‡·ÓÎfl‚‡ÌËfl (íàÄ, ËÌÒÛÎÚË), ‚ÂÌÓÁÌË ÚÓÏ·ÓÁË, ÂÔËÎÂÔÚ˘ÌË ÔÓfl‚Ë Ë ÏË„Â̇. Ç˙‚Âʉ‡ÌÂÚÓ Ì‡ ‰Ë‡„ÌÓÒÚ˘ÌË ÍËÚÂËË ÔÂÁ 1990„ ÓÚ Hodges, Warlow Ë Caplan ‰‡‚‡Ú ‚˙ÁÏÓÊÌÓÒÚ Á‡ ÔÓ ÚÓ˜ÌÓÚÓ Ë ÎÂÒÌÓ ÓÔ‰ÂÎflÌ ̇ Ì‚ÓÎӄ˘ÌËfl ÒË̉ÓÏ. àÁÒΉ‚‡ÌË Ò‡ 4 Ô‡ˆËÂÌÚ‡, ÔÓÍË‚‡˘Ë ÍËÚÂËËÚ Á‡ Ú‡ÁË ‡ÏÌÂÁËfl. ë‰̇ڇ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚ Ì‡ ÎËÔÒ‡Ú‡ ̇ Ô‡ÏÂÚ ÔË ËÁÒΉ‚‡ÌËÚ ԇˆËÂÌÚË Â 4 ˜‡Ò‡. 臈ËÂÌÚËÚ ҇ ËχÎË Ô˙Î̇ ‰ÂÁÓËÂÌÚ‡ˆËfl Á‡ ‚ÂÏÂ Ë ÏflÒÚÓ. ç‡ Ô‡ˆËÂÌÚËÚ Ò Ôӂ‰ üåê. èË ÚËχ ÓÚ Ô‡ˆËÂÌÚËÚ Ò ̇ÏÂË ÚÓÏ·ÓÁ‡ ̇ sinus sagitalis superior, ‡ ˜ÂÚ‚˙ÚËfl Â Ò ‰Û͈Ëfl ̇ Í˙‚ÓÚÓ͇ Ò ÌÂÔ˙Î̇ ÚÓÏ·ÓÁ‡.Ç ÎËÚÂ‡ÚÛ‡Ú‡  ÔÓ͇Á‡ÌÓ, ˜Â ÔË ·ÓÎÌË Ò Ú‡ÌÁËÚÓ̇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl Ëχ ÔÓÏÂÌË ‚˙‚ ‚ÂÌÓÁÌËfl Í˙‚ÓÚÓÍ Ë ÔÓ-χÎÍÓ ÒÎÛ˜‡Ë ̇ ËÌÚ‡‚ÂÌÓÁ̇ ÚÓÏ·ÓÁ‡. ç‡ÏÂÂÌËÚ ÓÚ Ì‡Ò ÔÓÏÂÌË Ò‡ ‚ ÔÓÚ‚˙ʉÂÌË ̇ Ú‡ÁË ÚÂÁ‡. äãûóéÇà Ñìåà: Ú‡ÌÁËÚÓ̇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl, ‚ÂÌÓÁ̇ ÚÓÏ·ÓÁ‡. í‡ÌÁËÚÓ̇ڇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl  Ò˙ÒÚÓflÌË ̇ ‚ÌÂÁ‡Ô̇ Ë ËÁÓÎË‡Ì‡ ‰ËÒÙÛÌ͈Ëfl ̇ Ô‡ÏÂÚÚ‡ Á‡ Ò˙·ËÚËfl ‚ ÔÓ‰˙ÎÊÂÌË ÓÚ ÌflÍÓÎÍÓ ÒÂÍÛÌ‰Ë ‰Ó ÌflÍÓÎÍÓ ˜‡Ò‡ ·ÂÁ ÌË͇͂‡ Á‡„Û·‡ ̇ Ò˙Á̇ÌËÂ, ·ÂÁ ‰‡ÌÌË Á‡ Ì‚ÓÎӄ˘ÌË Ë Í‡‰ËÓÎӄ˘ÌË ÔÓÏÂÌË ( 1,4, 6,10 ) . Ç˙ÁÏÓÊÌÓ Â, ÔÓ ‚ÂÏ ̇ ‡Ú‡Í‡Ú‡ ‰‡ ÔÓ‰˙ÎÊ‡Ú ‰‡ Ò ËÁ‚˙¯‚‡Ú ÓÚ‰ÂÎÌË ‰‚ËÊÂÌËfl ËÎË ‰‡ ÔÓ‰˙ÎÊ‡Ú Ú‡ÍË‚‡ ÓÚ Ô‰˯ÌÓ ‰ÂÈÒÚ‚ËÂ( ̇Ô˙ÎÌÓ ‡‚-

ÚÓχÚ˘ÌÓ), ÌÓ Á‡„Û·‡Ú‡ ̇ Ô‡ÏÂÚ Â Ô˙Î̇ Á‡ ÚÓÁË ÔÂËÓ‰ è‡ÚÓ„ÂÌÂÁ‡Ú‡ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ ‰Ó Ò„‡ Ì  ËÁflÒÌÂ̇. èӂ˜ÂÚÓ ÒÎÛ˜‡Ë ÔÛ·ÎËÍÛ‚‡ÌË ‚ ÎËÚÂ‡ÚÛ‡Ú‡ ÂÚËÓÎÓ„ËflÚ‡ ̇ ÒË̉Óχ  ҂˙Á‡Ì‡ Ò˙Ò ÒÎÛ˜‡Ë ̇ ËÒıÂÏ˘ÌË Ò˙‰Ó‚Ë Á‡·ÓÎfl‚‡ÌËfl( íàÄ, ËÌÒÛÎÚË ), ‚ÂÌÓÁÌË ÚÓÏ·ÓÁË, ÂÔËÎÂÔÚ˘ÌË ÔÓfl‚Ë Ë ÏË„Â̇ ( 4, 8, 10 ),. è˙‚ÓÚÓ ÓÔËÒ‡ÌË ̇ Ú‡ÌÁËÚÓ̇ڇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl  ÔÛ·ÎËÍÛ‚‡ÌÓ ÔÂÁ 1956„.ÓÚ Morris Bender ‚ Journal of the Hillside Hospital. ( 10 ) Ç˙‚Âʉ‡ÌÂÚÓ Ì‡ ‰Ë‡„ÌÓÒÚ˘ÌË ÍËÚÂËË ÔÂÁ 1990„ ÓÚ Hodges, Warlow Ë Caplan ‰‡‚‡Ú ‚˙ÁÏÓÊÌÓÒÚ Á‡ ÔÓ ÚÓ˜ÌÓÚÓ Ë ÎÂÒÌÓ ÓÔ‰ÂÎflÌ ̇ Ì‚ÓÎӄ˘ÌËfl ÒË̉ÓÏ. ( 10 )óÂÒÚÓÚ‡Ú‡ ̇ ÔÓfl‚‡ ÔÓ ‰‡ÌÌË Ì‡ Miller -Rochester Minnesota,  5.2 ÒÎÛ˜‡fl ̇ 100,000 ̇ÒÂÎÂÌËÂ, no ÔË Îˈ‡ ̇‰ 50 „  23.5 ̇ 100,000 ̇ÒÂÎÂÌËÂ. ñÖã ñÂΠ̇ ̇¯ÂÚÓ ËÁÒΉ‚‡Ì  Ô‰ÒÚ‡‚flÌÂÚÓ Ì‡ ÚÓÏ·ÓÁ‡ ̇ sinus sagitalis superior ͇ÚÓ ÂÚËÓÎӄ˘ÂÌ Ù‡ÍÚÓ Á‡ Ú‡ÌÁËÚÓ̇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl. åÄíÖêàÄã à åÖíéÑ àÁÒΉ‚‡ÌË Ò‡ 4 ·ÓÎÌË – 3 ÊÂÌË Ë Â‰ËÌ Ï˙Ê Ì‡ Ò‰̇ ‚˙Á‡ÒÚ 64.2 „ ( ÓÚ 61. 2 ‰Ó 68.8 „ ), ÍÓËÚÓ ÌflÏ‡Ú ‡Ì‡ÏÌÂÁ‡ Ë ‰ÓÍÛÏÂÌÚ‡ˆËfl Á‡ ÏË„Â̇, ÚÂÏÔÂ‡ÚÛ‡, ÂÔËÎÂÔÒËfl Ë ıÓÌ˘ÌÓ „·‚Ó·ÓÎËÂ, ÙÓÒÙÓÎËÔˉÂÌ ÒË̉ÓÏ. 臈ËÂÌÚËÚ Ì Ò˙Ó·˘‡‚‡Ú Ò˙˘Ó Á‡ Ô‰¯ÂÒÚ‚‡˘Ë ËÒıÂÏ˘ÌË ‡Ú‡ÍË, ËÚ˙ÏÌË Ì‡Û¯ÂÌËfl, ‰Ë‡·ÂÚ, ͇ÍÚÓ Ë ıÓÌ˘̇ ‡ÎÍÓıÓÎ̇ ÍÓÌÒÛχˆËfl ËÎË Â͈ËÒË‚ÌË ‡ÎÍÓıÓÎÌË ÔÓfl‚Ë.ç Ò ÛÒÚ‡ÌÓ‚fl‚‡Ú ‰‡ÌÌË Ì‡ Ú‡‚χ Ë ‡Ì‡ÏÌÂÁ‡ Á‡ ÂÔËÎÂÔÒËfl ‚ ÔÓÒΉÌËÚ ‰‚ „Ó‰ËÌË. 臈ËÂÌÚËÚ Ì ҇ ÔËÂÏÎË ıËÔÌÓÚˈË, ÌËÚÓ ËÁÔÓÎÁ‚‡ÎË ‰Ó„‡. èÓ‰˙ÎÊËÚÂÎÌÓÒÚÚ‡ ̇ ÎËÔÒ‡Ú‡ ̇ Ô‡ÏÂÚ Â ÓÚ 2 ˜‡Ò‡ ÔË Ô˙‚Ëfl, 4 ÔË ‰Û„ËÚ ‰‚‡Ï‡ ·ÓÎÌË Ë 6 ÔË ÔÓÒΉÌËfl ·ÓÎÂÌ.ë‰̇ڇ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚ Ì‡ ÎËÔÒ‡Ú‡ ̇ Ô‡ÏÂÚ Â 4 ˜‡Ò‡.臈ËÂÌÚËÚ ҇ ËχÎË Ô˙Î̇ ‰ÂÁÓËÂÌÚ‡ˆËfl Á‡ ‚ÂÏÂ Ë ÏflÒÚÓ. Ñ‚‡Ï‡ ÒΉ ‚˙ÁÒÚ‡ÌÓ‚fl‚‡Ì ̇ Ò˙ÒÚÓflÌËÂÚÓ Ò‡ Á‡‰‡ÎË ‚˙ÔÓÒ‡ “ ä˙‰Â Ò˙Ï ‡Á”. ÇÒ˘ÍËÚ ԇˆËÂÌÚË Ò‡ ·ËÎË Ò˙Ò Á‡Ô‡ÁÂ̇ ÒÂχÌÚ˘̇ Ô‡ÏÂÚ. Ö‰ËÌËfl Ô‡ˆËÂÌÚ Â ¯ÓÙË‡Î Ôӂ˜ ÓÚ 8 ˜‡Ò‡, ‰‚ÂÚ ԇˆËÂÌÚÍË Ò‡ ËχÎË ÂÏÓˆËÓ̇ÎÌË ÒÚÂÒÓ‚Â, ÔË ˜ÂÚ‚˙ÚËfl ·ÓÎÂÌ Ì‡ Ò ̇ÏÂË ÌË˘Ó ‡Á΢ÌÓ ÓÚ Ó·Ë˜‡ÈÌÓÚÓ ÔÂÏÓ·Ë‰ÌÓ Ò˙ÒÚÓflÌËÂ. èË ‚Ò˘ÍË ËÁÒΉ‚‡ÌË Ô‡ˆËÂÌÚË Ì‚ÓÎӄ˘ÌËfl ÒÚ‡ÚÛÒ ·Â¯Â ·ÂÁ ÓÚÍÎÓÌÂÌËfl. èӂ‰ÂÌËÚ ÖäÉ, ÖÖÉ, äÄí, ËÁÒΉ‚‡ÌËfl ·flı‡ ·ÂÁ ÓÚÍÎÓÌÂÌËfl ÓÚ ÂÙÂÂÌÚÌËÚ „‡ÌˈË. ÖÎÂÍÚÓÎËÚÌËfl Ô‡ÌÂÎ, ÍÓ‡„Û·ˆËÓÌÂÌ ÒÚ‡ÚÛÒ, èää ·flı‡ Ò˙˘Ó ·ÂÁ Ô‡ÚÓÎӄ˘̇ ÔÓÏfl̇. ÖÍÒÚ‡ Ë Ú‡ÌÒÍ‡ÌˇÎ̇ڇ ÑÓÔÎÂÓ‚‡ ÒÓÌÓ„‡ÙËfl ̇ ‡ÚÂˇÎÌËÚ Ò˙‰Ó‚ ·flı‡ ·ÂÁ Ô‡ÚÓÎӄ˘̇ ÒÓÌÓ„‡ÙÒ͇ ̇ıӉ͇. ç‡ Ô‡ˆËÂÌÚËÚ Ò Ôӂ‰ üåê ÔÓ ËÁ‚ÂÒÚ̇ ÏÂÚÓ‰Ë͇ (2, 7,11 ). èË ÚËχ ÓÚ Ô‡ˆËÂÌÚËÚ Ò ̇ÏÂË ÚÓÏ·ÓÁ‡ ̇ sinus sagitalis superior, ‡ ˜ÂÚ‚˙ÚËfl Ò ‰Û͈Ëfl ̇ Í˙‚ÓÚÓ͇ Ò ÌÂÔ˙Î̇ ÚÓÏ·ÓÁ‡. OÅëöÜÑÄçÖ äËÚÂËËÚÂ, Ô‰ÎÓÊÂÌË Ë ÔËÂÚË Á‡ ‰Ë‡„ÌÓÒÚË͇ ̇ ÔÂıӉ̇ڇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl ÔÓ͇Á‚‡Ú, ˜Â Ô‡ˆËÂÌÚËÚ ÓÚ„Ó‚‡flÚ Ì‡ Úflı.Ç˙ÔÂÍË ÚÓ‚‡ Ò ӷÒ˙ʉ‡ı‡ Ë ‰Û„Ë ‚˙ÁÏÓÊÌË ‰ËÙÂÂ̈ˇÎÌÓ- ‰Ë‡„ÌÓÒÚ˘ÌË ÔÓ·ÎÂÏË Í‡ÚÓ: Ú‡‚χÚ˘̇ „ÂÌÂÁ‡ (ڇ͇‚‡ Ìflχ¯Â ÓÚ ‡Ì‡ÏÌÂÁ‡Ú‡), ıËÒ-


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MRI ‚ÂÌÓ„‡ÙËfl – ËÁ‡ÁÂ̇ ‰Û͈Ëfl ̇ Í˙‚ÓÚÓ͇ ̇ sinus sagitalis superior ÚÂ˘̇, ‡Ù‡ÁËË, Ô‡‡‡ÏÌÂÁËË Ë ÍÓÌÙÛ·Û·ˆËË, Â̈ÂÙ‡ÎËÚË, ÍÓËÚÓ ·flı‡ ËÁÍβ˜ÂÌË ÓÚ Ôӂ‰ÂÌËÚ ËÁÒΉ‚‡ÌËfl. Lewis ÔÓ͇Á‚‡, ˜Â ‚ÂÌÓÁ̇ڇ ÍÓÌ„ÂÒÚËfl Ô˘ËÌfl‚‡ ̇Û¯ÂÌ Í˙‚ÂÌ ÚÓÍ Ì‡ ڇ·ÏÛÒ‡ ËÎË ÚÂÏÔÓ‡ÎÌËÚ ÒÚÛÍÚÛË ( 5).Ç ÎËÚÂ‡ÚÛ‡Ú‡ Ëχ ÔÛ·ÎË͇ˆËË, ˜Â ÔË ·ÓÎÌË Ò ÓÍÎÛÁËfl ̇ ·‡ıËÓˆÂÙ‡Î̇ڇ ‚Â̇ Ëχ ÂÚÓ„‡‰ÂÌ Í˙‚ÂÌ ÚÓÍ. Ä‚ÚÓËÚ ÔÓ͇Á‚‡Ú, ˜Â Ô‡ˆËÂÌÚËÚ ËÏ‡Ú ÒÌËÊÌÓ ÏÓÁ˙˜ÌÓ ‚ÂÌÓÁÌÓ ÓÚÚ˘‡ÌÂ, ÍÓÂÚÓ Ï‡ÍË‡ ËÒ͇ Ú‡ÌÁËÚÓ̇ „ÎÓ·‡Î̇ ‡ÏÌÂÁËfl ( 3). àÁÒΉ‚‡ÌËÚ ÓÚ Ì‡Ò Ô‡ˆËÂÌÚË Ò‡ Ò ‚ÂÌÓÁ̇ ÚÓÏ·ÓÁ‡ ̇ sinus sagitalis superior ËÎË ÒËÎÌÓ ‰ۈË‡Ì Í˙‚ÂÌ ÚÓÍ, ÍÓÂÚÓ ÏÓÊ ‰‡ Ò ҂˙Ê ͇ÚÓ ÔflÍ ÂÚËÓÔ‡ÚÓ„ÂÌÂÚ˘ÂÌ Ù‡ÍÚÓ Á‡ ÒË̉Óχ ̇ „ÎÓ·‡Î̇ Ú‡ÌÁËÚÓ̇ ËÒıÂÏËfl, ÒΉ ͇ÚÓ ·flı‡ ËÁÍβ˜ÂÌË ‚Ò˘ÍË ‰Û„Ë ‚˙ÁÏÓÊÌË ‰ËÙÂÂ̈ˇÎÌÓ-‰Ë‡„ÌÓÒÚ˘ÌË ‚˙ÁÏÓÊÌÓÒÚË Ë ·flı‡ ÔÓÍËÚË ÍËÚÂËËÚ ̇ Hodges, Warlow Ë Caplan. íÓ‚‡ ÔÓÚ‚˙ʉ‡‚‡ ÚÂÁ‡Ú‡ Á‡ Ô‡ÚÓÎÓ„Ëfl ̇ ÔÓ‚˙ıÌÓÒÚÌËfl ‚ÂÌÓÁÂÌ Í˙„, ˜ËflÚÓ ÍÎËÌ˘̇ ÔÓfl‚‡  „ÎÓ·‡Î̇ Ú‡ÌÁËÚÓ̇ ‡ÏÌÂÁËfl.( 10 ) ãàíÖêÄíìêÄ 1. 2. 3. 4. 5. 6.

Adams RD, Victor M, Ropper AH: Transient global amnesia. Principles of Neurology. New York: McGraw-Hill; 1997: 429-30. Ay H, Furie KL, Yamada K, Koroshetz WJ: Diffusion-weighted MRI characterizes the ischemic lesion in transient global amnesia. Neurology 1998 Sep; 51(3): 901-3. Chung CP, Hsu HY, Chao AC, et al: Detection of intracranial venous reflux in patients of transient global amnesia. Neurology 2006 Jun 27; 66(12): 18737. Hinge HH, Jensen TS, Kjaer M, et al: The prognosis of transient global amnesia. Results of a multicenter study. Arch Neurol 1986 Jul; 43(7): 673-6. Lewis SL: Aetiology of transient global amnesia. Lancet 1998 Aug 1; 352(9125): 397-9 Miller JW, Petersen RC, Metter EJ, et al: Transient global amnesia: clinical

characteristics and prognosis. Neurology 1987 May; 37(5): 733-7. Nakada T, Kwee IL, Fujii Y, Knight RT: High-field, T2 reversed MRI of the hippocampus in transient global amnesia. Neurology 2005 Apr 12; 64(7): 1170-4 8. Schmidtke K, Ehmsen L: Transient global amnesia and migraine. A case control study. Eur Neurol 1998 Jul; 40(1): 9-14 9. Schreiber SJ, Doepp F, Klingebiel R, Valdueza JM: Internal jugular vein valve incompetence and intracranial venous anatomy in transient global amnesia. J Neurol Neurosurg Psychiatry 2005 Apr; 76(4): 509-13 10. Shuping JR, Rollinson RD, Toole JF: Transient global amnesia. Ann Neurol 1980 Mar; 7(3): 281-85 11. Strupp M, Bruning R, Wu RH, et al: Diffusion-weighted MRI in transient global amnesia: elevated signal intensity in the left mesial temporal lobe in 7 of 10 patients. Ann Neurol 1998 Feb; 43(2): 164-70. 7.


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Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

90

éË„Ë̇ÎÌË ÒÚ‡ÚËË àáåÖêÇÄçÖ çÄ ÇêÖåÖÇàíÖ èÄêÄåÖíêà çÄ ÇÄêàÄÅàãçéëííÄ çÄ ëöêÑÖóçÄíÄ óÖëíéíÄ èêà 2 íàè ÑàÄÅÖíàñà Ç ìëãéÇàüíÄ çÄ éêíéíÖëí à. ÑÓÏÛҘ˂ å‰ˈËÌÒÍË ËÌÒÚËÚÛÚ-ñÂÌÚ‡Î̇ ÍÎËÌ˘̇ ·‡Á‡-åÇê, „. ëÓÙËfl éÚ‰ÂÎÂÌË ÔÓ ẨÓÍËÌÓÎÓ„Ëfl SUMMARY MEASUREMENT OF TIME-DOMAIN PARAMETERS OF HEART RATE VARIABILITY IN TYPE 2 DIABETICS IN CONDITIONS OF ORTHOTEST Ivan Domuschiev Medical Institute-Central Clinical Base-Ministry of Inrerior, Sofia Department of Endocrinology The HRV-analysis is an important method for quantitative valuation of vegetative control on sinus nodul. The aim of this study is trough the short-term spectral analysis of HRV to compare the value of time-domain parameters flatways and after a orthotest in 2 type diabetics. Material and methods: the study include 12 patients (9 male and 3 female). The average age of the patients is 55,33 + _ 15, 77. A short-term (6 minutes) spectral analysis is made. The time-domain parameters ( SD, Variance, SDNN, NN50, pNN50, RMSSD ) are measured. Results: The time-domain parameters (SD, Variance, SDNN, NN50,RMSSD) are nonsignificant lower flatways compared the value after the orthotest. Conclusions: 1/ The 2 type diabetics show after the orthotest inadequate activation of sympathetic department of vegetative nervous system; 2/ a simpatho-vagal inbalance is present. KEYWORDS: heart rate variability, spectral analysis, time-domain parameters, diabetes mellitus, orthotest. êÖáûåÖ ëÔÂÍÚ‡ÎÌËflÚ ‡Ì‡ÎËÁ ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ /HRV/ Ò fl‚fl‚‡ ‚‡ÊÂÌ ÏÂÚÓ‰ Á‡ ÍÓ΢ÂÒÚ‚Â̇ ÓˆÂÌ͇ ̇ ‚ÎËflÌËÂÚÓ Ì‡ ‡‚ÚÓÌÓÏ̇ڇ ÌÂ‚̇ ÒËÒÚÂχ ‚˙ıÛ ÒËÌÛÒÓ‚Ëfl ‚˙ÁÂÎ . ñÂÎÚ‡ ̇ ÔÓÛ˜‚‡ÌÂÚÓ Â Ò ÔÓÏÓ˘‡ ̇ Í‡ÚÍÓÚ‡ÈÌËfl ÒÔÂÍÚ‡ÎÂÌ ‡Ì‡ÎËÁ ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ ‰‡ Ò‡‚ÌËÏ ÒÚÓÈÌÓÒÚËÚ ̇ ‚ÂÏ‚ËÚÂ È Ô‡‡ÏÂÚË, ËÁÏÂÂÌË ‚ ΄̇ÎÓ Ë ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ, ÔË ÔÓ‚Âʉ‡Ì ̇ ÓÚÓÚÂÒÚ ÔË 2 ÚËÔ ‰Ë‡·ÂÚˈËÚÂ. å‡ÚÂË‡Î Ë ÏÂÚÓ‰Ë: ̇Ô‡‚ÂÌÓÚÓ ÍÎËÌ˘ÌÓ ÔÓÛ˜‚‡Ì ӷı‚‡˘‡ 12 Ô‡ˆËÂÌÚË – 9 (75.00%) Ï˙ÊÂ Ë 3 (25,00%) ÊÂÌË . ë‰̇ڇ ‚˙Á‡ÒÚ Ì‡ ËÁÒΉ‚‡ÌËfl ÍÓÌÚËÌ„ÂÌÚ Â 55,33±15,77 „. ‚ ‰Ë‡Ô‡ÁÓ̇ ÓÚ 32 ‰Ó 74 „Ó‰ËÌË. èË ‚Ò˘ÍË Îˈ‡  Ôӂ‰ÂÌ 6-ÏËÌÛÚÂÌ Á‡ÔËÒ Ì‡ HRV. àÁÏÂÂÌË Ò‡ ‚ÂÏ‚ËÚ ԇ‡ÏÂÚË Ì‡ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜ÌËfl ËÚ˙Ï /SD, Variance, SDNN, NN50, pNN50, RMSSD/. êÂÁÛÎÚ‡ÚË: Ôӂ‰ÂÌËflÚ ÒÚ‡ÚËÒÚ˘ÂÒÍË ‡Ì‡ÎËÁ ÔÓ͇Á‚‡ ÌÂÒË„ÌËÙË͇ÌÚÌÓ ÔÓ-ÌËÒÍË ÒÚÓÈÌÓÒÚË Ì‡ ‰Ë‡·ÂÚˈËÚ ‚ ΄̇ÎÓ ÔÓÎÓÊÂÌË ‚ Ò‡‚ÌÂÌËÂ Ò ËÁÔ‡‚ÂÌÓÚÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ ÔË ÔÓ͇Á‡ÚÂÎËÚ SDNN, RMSSD, NN50, Variance Ë SD. àÁ‚Ó‰Ë:1/ èË ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ·ÓÎÌËÚ ÓÚ 2 ÚËÔ Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÔÓ͇Á‚‡Ú ̇‰ÂÍ‚‡ÚÌÓ ‡ÍÚË‚Ë‡Ì ̇ ÒËÏÔ‡ÚËÍÛÒÓ‚Ëfl ÓÚ‰ÂΠ̇ ‚„ÂÚ‡Ú˂̇ڇ ÌÂ‚̇ ÒËÒÚÂχ; 2/ ̇Îˈ  ÒËÏÔ‡ÚÓ-‚‡„‡ÎÂÌ ‰ËÒ·‡Î‡ÌÒ. äãûóéÇà Ñìåà: ‚‡ˇ·ËÎÌÓÒÚ Ì‡ Ò˙‰Â˜ÌËfl ËÚ˙Ï, ÒÔÂÍÚ‡ÎÂÌ ‡Ì‡ÎËÁ, ‚ÂÏÂ‚Ë Ô‡‡ÏÂÚË, Á‡ı‡ÂÌ ‰Ë‡·ÂÚ, ÓÚÓÚÂÒÚ.

ìÇéÑ ëÔÂÍÚ‡ÎÌËflÚ ‡Ì‡ÎËÁ ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ /Çëó=HRV/ Ò fl‚fl‚‡ ‚‡ÊÂÌ ÏÂÚÓ‰ Á‡ ÍÓ΢ÂÒÚ‚Â̇ ÓˆÂÌ͇ ̇ ‚ÎËflÌËÂÚÓ Ì‡ ‡‚ÚÓÌÓÏ̇ڇ ÌÂ‚̇ ÒËÒÚÂχ ‚˙ıÛ ÒËÌÛÒÓ‚Ëfl ‚˙ÁÂÎ / 1 /. íÓÈ ÔÓÁ‚ÓÎfl‚‡ ‰‡ Ò ÓÔ‰ÂÎË Û˜‡ÒÚËÂÚÓ Ì‡ ‚‡„ÛÒ‡ Ë ÒËÏÔ‡ÚËÍÛÒ‡ ‚˙ıÛ Ò˙‰Â˜ÌÓÒ˙‰Ó‚‡Ú‡ ÒËÒÚÂχ ÔË ˜Ó‚Â͇. HRV-‡Ì‡ÎËÁ˙Ú ÔÓχ„‡ Á‡ ‚˙ÁÔËÂχÌÂÚÓ Ì‡ Ò˙‰Â˜ÌÓ-Ò˙‰Ó‚ËÚ Ò˄̇ÎË Ì ҇ÏÓ Í‡ÚÓ ÒÚ‡Ú˘ÌÓ, ÌÓ Ë Í‡ÚÓ ‰Ë̇Ï˘ÌÓ fl‚ÎÂÌË / 2 /. àÁ‚ÂÒÚÌÓ Â, ˜Â ÔË ·ÓÎÌËÚ ÓÚ Á‡ı‡ÂÌ ‰Ë‡·ÂÚ Ò ‡Á‚Ë‚‡ ‡‚ÚÓÌÓÏ̇ Ì‚ÓÔ‡ÚËfl. èÓÒΉ̇ڇ  ҂˙Á‡Ì‡ Ò Ôӂ˯Â̇ ÒÏ˙ÚÌÓÒÚ ÔÓ‡‰Ë Ò˙‰Â˜ÌÓ-Ò˙‰Ó‚Ë Ë̈ˉÂÌÚË / 3 /. èË 2 ÚËÔ ‰Ë‡·ÂÚˈËÚ ‰ۈË‡Ì‡Ú‡ ‚‡ˇ·ËÎÌÓÒÚ Ì‡ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡  ‡ÒÓˆËË‡Ì‡ Ò 4-Í‡ÚÌÓ ÔÓ-‚ËÒÓÍ ËÒÍ ÓÚ Ò˙‰Â˜ÌÓ-Ò˙‰Ó‚‡ ÒÏ˙Ú ‚ Ò‡‚ÌÂÌËÂ Ò Ì‰ˇ·ÂÚˈËÚ / 4 /. íÓÁË Ù‡ÍÚ Ó˜ÂÚ‡‚‡ „ÓÎflÏÓÚÓ Á̇˜ÂÌË ̇ Ô‚Â̈ËflÚ‡ ÓÚ ‰Ë‡·ÂÚ̇ ‡‚ÚÓÌÓÏ̇ Ì‚ÓÔ‡ÚËfl. ê‰ۈË‡Ì‡Ú‡ ‚‡ˇ·ËÎÌÓÒÚ Ì‡ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡  ‡ÌÂÌ ·Â΄ ̇ ÒËÒÚÂÏÌË ‰Ë‡·ÂÚÌË ÛÒÎÓÊÌÂÌËfl. ñÂÎÚ‡ ̇ ̇¯ÂÚÓ ÔÓÛ˜‚‡ÌÂ Â Ò ÔÓÏÓ˘‡ ̇ Í‡ÚÍÓÚ‡ÈÌËfl ÒÔÂÍÚ‡ÎÂÌ ‡Ì‡ÎËÁ ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ ‰‡ Ò‡‚ÌËÏ ÒÚÓÈÌÓÒÚËÚ ̇ ‚ÂÏ‚ËÚÂ È Ô‡‡ÏÂÚË, ËÁÏÂÂÌË ‚ ΄̇ÎÓ Ë ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ, ÔË ÔÓ‚Âʉ‡Ì ̇ ÓÚÓÚÂÒÚ ÔË 2 ÚËÔ ‰Ë‡·ÂÚˈËÚÂ. åÄíÖêàÄã à åÖíéÑà çÄ àáëãÖÑÇÄçÖ ç‡Ô‡‚ÂÌÓÚÓ ÍÎËÌ˘ÌÓ ÔÓÛ˜‚‡Ì ӷı‚‡˘‡ 12 Ô‡ˆËÂÌÚË – 9 (75.00%) Ï˙ÊÂ Ë 3 (25,00%) ÊÂÌË (ÙË„. 1). ë‰̇ڇ ‚˙Á‡ÒÚ Ì‡ ËÁÒΉ‚‡ÌËfl ÍÓÌÚËÌ„ÂÌÚ Â 55,33±15,77 „. ‚ ‰Ë‡Ô‡ÁÓ̇ ÓÚ 32 ‰Ó 74 „Ó‰ËÌË. ãˈ‡Ú‡, ÍÓËÚÓ Ò‡ ÔËÂχÎË Ï‰Ë͇ÏÂÌÚË, ÍÓËÚÓ ÔÓ‚-

îË„Û‡ 1: ê‡ÁÔ‰ÂÎÂÌË ̇ ËÁÒΉ‚‡ÌËfl ÍÓÌÚËÌ„ÂÌÚ ÔÓ ÔÓÎÓ‚‡ ÔË̇‰ÎÂÊÌÓÒÚ


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

91

ÎËfl‚‡Ú ‚„ÂÚ‡Ú˂̇ڇ ÌÂ‚̇ ÒËÒÚÂχ /·ÂÚ‡-·ÎÓÍÂË, ÌËÚ ÔÓÏÂÌË) ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡. ● pNN50 - ÔÓˆÂÌÚ‡ ̇ ÔÓÒΉӂ‡ÚÂÎÌËÚ ËÌÚÂ‚‡ÎË, ÒËÏÔ‡ÚËÍÓÎËÚˈË, ‡ÌÚËıÓÎËÌÂ„˘ÌË Ò‰ÒÚ‚‡, ÏËÌÂÍÓËÚÓ Ò ‡Á΢‡‚‡Ú Ò Ôӂ˜ ÓÚ 50 ms. èÓÌÂÊ Ò ‡ÎÍÓÚËÍÓˉË, ÔÒËıÓÙ‡χ͇- ‡ÏËÚËÔÚËÎËÌ, ÍÎÓÁ‡ÓÔ‰ÂÎfl ÓÚ Ò˙Ò‰ÌË ËÌÚÂ‚‡ÎË, Ò˙˘Ó ÓÚ‡Áfl‚‡ ÔËÌ/ Ì ҇ ‚Íβ˜ÂÌË ‚ ÚÓ‚‡ ËÁΉ‚‡ÌÂ. ÇÒ˘ÍË ËÁÒΉ‚‡ÌË ·˙ÁËÚ (‚ËÒÓÍÓ˜ÂÒÚÓÚÌË ÔÓÏÂÌË) ̇ ‚‡ˇ·ËÎÌÓÎˈ‡ 6 ˜‡Ò‡ ÔÂ‰Ë ËÁÒΉ‚‡ÌÂÚÓ Ì ҇ ÔËÂχÎË ÌËÍÓÚËÌ ÒÚÚ‡. Ë Í‡Ù /ÍÓÙÂËÌ/. ● NN50 - ·ÓflÚ (Ì ÔÓˆÂÌÚ‡) ̇ ÔÓÒΉӂ‡ÚÂÎÌËÚ èË ‚Ò˘ÍË Îˈ‡  Ôӂ‰ÂÌ 6-ÏËÌÛÚÂÌ Á‡ÔËÒ Ì‡ HRV Ò ËÌÚÂ‚‡ÎË, ÍÓËÚÓ Ò ‡Á΢‡‚‡Ú Ò Ôӂ˜ ÓÚ 50 ms. ÔÓÏÓ˘Ú‡ ̇ “Polar Advantage Interface” Ò Polar ● àÁÏÂÂÌ Â Ò˙˘Ó ڇ͇ Ë „ÂÓÏÂÚ˘ÌËflÚ Ô‡‡ÏÂÚ˙ Precision Performance Software Version 3 (Á‡ Windows)HRV id / HRV triangular index = Úˇ̄Û·ÂÌ ËÌÔÓËÁ‚Ó‰ÒÚ‚Ó Ì‡ Polar Electro Oy ( îËÌ·̉Ëfl). àÁÒΉ‰ÂÍÒ/. íÓÈ Ò ËÁ˜ËÒÎfl‚‡ Ò ÔÓÏÓ˘Ú‡ ̇ „ÂÓÏÂÚ˘ÌË ‚‡ÌÂÚÓ Â Ôӂ‰ÂÌÓ ‚ ÛÒÎÓ‚ËflÚ‡ ̇ Ô˙ÎÂÌ ÔÓÍÓÈ ‚ ˜‡ÒÓ‚ÂÏÂÚÓ‰Ë Ì‡ ËÁÏÂ‚‡Ì ̇ HRV. Ç ÚÓÁË ÒÎÛ˜‡È HRV ͇Ú ÔÂ‰Ë Ó·fl‰. ëÔÂÍÚ‡ÎÌËflÚ ‡Ì‡ÎËÁ Ò ·‡ÁË‡ ̇ ·˙Á‡ÚÓ ˆflÎÓ Ò ӈÂÌfl‚‡ ÔÓÒ‰ÒÚ‚ÓÏ ËÁ˜ËÒÎÂÌË ̇ ÓÒÌÓÚ‡ Ú‡ÌÒÙÓχˆËfl ̇ îÛË /Fast Fourie Transformation = ‚‡Ú‡ ̇ ÚË˙„˙ÎÌË͇, ÔÓÎÛ˜ÂÌ Ì‡ ıËÒÚÓ„‡Ï‡Ú‡ ˜ÂÁ FFT/. ëÔˆˇÎËÁË‡Ì‡Ú‡ ÍÓÏÔ˛Ú˙̇ ÔÓ„‡Ï‡ ‡‚ÚÓχ‡ÁÔ‰ÂÎÂÌËÂÚÓ Ì‡ ÒËÌÛÒÓ‚ËÚ RR-ËÌÚÂ‚‡ÎË. Ú˘ÌÓ ËÁı‚˙Îfl ÓÚ Á‡ÔËÒ‡ ‚Ò˘ÍË ÔÓÎÛ˜ÂÌË ‡ÚÂÙ‡ÍÚË HRV id Ò ËÁ‡Áfl‚‡ ‚ ÚÂıÌ˘ÂÒÍË Â‰ËÌˈË, ‚Òfl͇ ÓÚ /‚Íβ˜ËÚÂÎÌÓ ‚Ò˘ÍË ÂÍÒÚ‡ÒËÒÚÓÎË/. àÁÏÂ‚‡Ú Ò ҇ÏÓ ÍÓËÚÓ Ò˙ÓÚ‚ÂÚÒÚ‚‡ ̇ 7,8 ÏÒ. ËÌÚÂ‚‡ÎËÚ ÏÂÊ‰Û ÌÓχÎÌËÚ ÒËÌÛÒÓ‚Ë Ò˙Í‡˘ÂÌËfl, чÌÌËÚ ·flı‡ ‚˙‚‰ÂÌË Ë Ó·‡·ÓÚÂÌË Ò˙Ò ÒÚ‡ÚËÒÚËÁ‡˘ÓÚÓ Ò‡ÏÓ Ú ÓÚ‡Áfl‚‡Ú ‚„ÂÚ‡Ú˂̇ڇ ËÌÂ‚‡ˆËfl ̇ Ò˙ˆÂÚÓ /Ó·ÓÁ̇˜‡‚‡Ú Ò ͇ÚÓ NN-ËÌÚÂ‚‡ÎË/. àÁ- ˜ÂÒÍËfl Ô‡ÍÂÚ SPSS 13.0.1. ᇠÌË‚Ó Ì‡ Á̇˜ËÏÓÒÚ, ÔË ÍÓÏÂ‚‡ÌÂÚÓ Ì‡ HRV e ËÁ‚˙¯ÂÌÓ ‚ Ò˙ÓÚ‚ÂÚÒÚ‚ËÂ Ò Task ÂÚÓ Ò ÓÚı‚˙Îfl ÌÛ΂‡Ú‡ ıËÔÓÚÂÁ‡, ·Â ËÁ·‡ÌÓ p < 0,05. Force of the European Society of Cardiology and the North Åflı‡ ÔËÎÓÊÂÌË ÒΉÌËÚ ÒÚ‡ÚËÒÚ˘ÂÒÍË ÏÂÚÓ‰Ë: American Society of Pacing Electrophysiology / 6 /. 1. ÑÂÒÍËÔÚË‚ÂÌ ‡Ì‡ÎËÁ – ‚ Ú‡·Î˘ÂÌ ‚ˉ  Ô‰ÒÚ‡‚ÂLJˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜ÌËfl ËÚ˙Ï Ò Ò˙ÒÚÓË ÓÚ í‡·Îˈ‡ 1. ë‡‚ÌËÚÂÎÂÌ ‡Ì‡ÎËÁ ̇ ËÁÒΉ‚‡ÌËÚ ÔÓ͇Á‡ÚÂÎË ‚ ΄̇ÎÓ ÔÓÎÓÊÂÌËÂ Ë ÒΉ ÓÚÓÚÂÒÚ‡ èÓ͇Á‡ÚÂÎ

SDNN RMSSD NN50 pNN50 HRVid Variance St.Deviat.

N

12 12 12 12 12 12 12

ï

ã„̇ÎÓ ÔÓÎÓÊÂÌË SD

39,93 42,49 17,58 8,39 15,50 4,43 41,39

25,40 39,60 7,74 13,78 6,36 2,37 27,62

Min

15,20 15,18 6,00 1,46 8,00 1,74 15,20

Max

ï

85,34 117,35 31,00 51,51 32,00 8,77 86,35

˜ÂÒÚÓÚÌË Ë ‚ÂÏÂ‚Ë Ô‡‡ÏÂÚË. Ç Ú‡ÁË ÒÚ‡ÚËfl Ô‰ÏÂÚ Ì‡ ËÁÒΉ‚‡Ì Ò fl‚fl‚‡Ú ‚ÂÏ‚ËÚ ԇ‡ÏÂÚË Ì‡ Çëó. ëÔÂÍÚ‡ÎÌËflÚ ‡Ì‡ÎËÁ Ô‰ÒÚ‡‚fl Í‡È̇ڇ Ò˙‰Â˜Ì‡ ˜ÂÒÚÓÚ‡ ͇ÚÓ ÒÛχ ÓÚ ‡Á΢ÌÓ ÒËÎÌË ˆËÍ΢ÌË ‚˙Á‰ÂÈÒÚ‚Ëfl Ò ‡Á΢ÌÓ ‰˙Î˙„ ˆËÍ˙Î. ÇÂÏ‚ËflÚ ‡Ì‡ÎËÁ ̇ Çëó Ò ·‡ÁË‡ ̇ ÒÚ‡ÚËÒÚ˘ÂÒÍËfl ‡Ì‡ÎËÁ ̇ ËÁÏÂÌÂÌËflÚ‡ ̇ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚÚ‡ ̇ ÔÓÒΉӂ‡ÚÂÎÌËÚ RR-ËÌÚÂ‚‡ÎË ÏÂÊ‰Û ÒËÌÛÒÓ‚ËÚ Ò˙Í‡˘ÂÌËfl Ò ËÁ˜ËÒÎfl‚‡Ì ̇ ‡Á΢ÌË ÍÓÂÙˈËÂÌÚË. àÁÔÓÎÁÛ‚‡Ú Ò ÒΉÌËÚ ‚ÂÏÂ‚Ë Ô‡‡ÏÂÚË: Standart Deviation /Òڇ̉‡ÚÌÓ ÓÚÍÎÓÌÂÌËÂ/-Ú‡ÁË ‚Â΢Ë̇ Á‡‚ËÒË ÓÚ ·Ófl ̇ ËÁÒΉ‚‡ÌËÚ RR-ËÌÚÂ‚‡ÎË. чÊ ÔË Â‰Ì‡Í‚Ó ‚ÂÏ ̇ ËÁÒΉ‚‡Ì ·ÓflÚ Ì‡ RR-ËÌÚÂ‚‡ÎËÚ Ò ÔÓÏÂÌfl ÔÓ‡‰Ë ‡Á΢̇ڇ Ò˙‰Â˜Ì‡ ˜ÂÒÚÓÚ‡. Variance /‚‡ˇˆËÓÌÂÌ ÍÓÂÙˈËÂÌÚ/-ËÁ˜ËÒÎfl‚‡ ÒÂ, ͇ÚÓ Òڇ̉‡ÚÌÓÚÓ ÓÚÍÎÓÌÂÌË Ò ‡Á‰ÂÎË Ì‡ Ò‰̇ڇ ÔÓ‰˙ÎÊËÚÂÎÌÓÒÚ Ì‡ RR-ËÌÚÂ‚‡ÎËÚ (SD/mean RR) ● SDNN /ËÁÏÂ‚‡ Ò ‚ ÏËÎËÒÂÍÛÌ‰Ë = ÏÒ/ - ÓÔ‰ÂÎfl Ò ‚˙Á ÓÒÌÓ‚‡ ̇ ÌÓχÎÌËÚ NN - ËÌÚÂ‚‡ÎË, ͇ÚÓ Ò ËÁ˜ËÒÎfl‚‡ ÚflıÌÓÚÓ Òڇ̉‡ÚÌÓ ÓÚÍÎÓÌÂÌËÂ. ● rMSSD /‚ ÏËÎËÒÂÍÛ̉Ë/ - Ò‰ÌÓ Í‚‡‰‡Ú˘ÌÓ Ì‡ ‡ÁÎËÍËÚ ÏÂÊ‰Û ‚ÒÂÍË ‰‚‡ ÔÓÒΉӂ‡ÚÂÎÌË ÌÓχÎÌË RR. íÓÂÒÚ ÚÓÈ ÓÚ‡Áfl‚‡ ·˙ÁËÚ (‚ËÒÓÍÓ˜ÂÒÚÓÚ-

52,91 51,76 31,00 7,13 15,58 6,94 52,85

éÚÓÚÂÒÚ SD Min

27,49 45,23 47,41 14,28 9,82 3,15 27,56

20,03 12,66 4,00 0,80 8,00 3,28 20,03

Max

26,08 52,29 49,59 5,76 7484,00 0,020 319,20 110,78 152,85 174,00 51,94 45,00 13,43 110,78

n.s. n.s. n.s. n.s. n.s. n.s. 0.004 n.s. n.s. n.s. n.s. n.s. n.s. n.s.

ÌÓ ˜ÂÒÚÓÚÌÓÚÓ ‡ÁÔ‰ÂÎÂÌË ̇ ‡Á„ÎÂʉ‡ÌËÚ ÔËÁ̇ˆË, ‡Á·ËÚË ÔÓ „ÛÔË Ì‡ ËÁÒΉ‚‡ÌÂ. 2. LJˇˆËÓÌÂÌ ‡Ì‡ÎËÁ – ËÁ˜ËÒÎfl‚‡Ì ӈÂÌÍËÚ ̇ ˆÂÌÚ‡Î̇ڇ ÚẨÂ̈Ëfl Ë ‡ÁÒÂÈ‚‡ÌÂ. 3. É‡Ù˘ÂÌ ‡Ì‡ÎËÁ – Á‡ ‚ËÁÛ‡ÎËÁ‡ˆËfl ̇ ÔÓÎÛ˜ÂÌËÚ ÂÁÛÎÚ‡ÚË. 4. ÖÍÁ‡ÍÚÂÌ ÚÂÒÚ Ì‡ î˯Â Á‡ ÔÓ‚Â͇ ̇΢ËÂÚÓ Ì‡ ‚˙Á͇ ÏÂÊ‰Û ‰‚‡ ͇Ú„ÓËÈÌË ÔËÁ͇̇. 5. íÂÒÚ Ì‡ äÓÎÏÓ„ÓÓ‚-ëÏËÌÓ‚ Á‡ ÔÓ‚Â͇ ‚ˉ‡ ̇ ‡ÁÔ‰ÂÎÂÌËÂÚÓ. 6. í-ÍËÚÂËÈ Ì‡ ëÚ˛‰˙ÌÚ Á‡ ‰‚ ÌÂÁ‡‚ËÒËÏË ËÁ‚‡‰ÍË. 7. çÂÔ‡‡ÏÂÚ˘ÂÌ ÚÂÒÚ Ì‡ Mann-Whitney Á‡ ‰‚ ÌÂÁ‡‚ËÒËÏË ËÁ‚‡‰ÍË. êÖáìãíÄíà èӂ‰ÂÌËflÚ ÒÚ‡ÚËÒÚ˘ÂÒÍË ‡Ì‡ÎËÁ ÔÓ͇Á‚‡ ÌÂÒË„ÌËÙË͇ÌÚÌÓ ÔÓ-ÌËÒÍË ÒÚÓÈÌÓÒÚË Ì‡ ‰Ë‡·ÂÚˈËÚ ‚ ΄̇ÎÓ ÔÓÎÓÊÂÌË ‚ Ò‡‚ÌÂÌËÂ Ò ËÁÔ‡‚ÂÌÓÚÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ ÔË ÔÓ͇Á‡ÚÂÎËÚÂ: SDNN, RMSSD, NN50, HRVid, Variance Ë St.Deviat./SD/ (Ú‡·Î. 1, ÙË„. 2 ). èÓ͇Á‡ÚÂÎflÚ pNN50 ‰ËÌÒÚ‚ÂÌÓ ÔÓ͇Á‚‡ ÌÂÒË„ÌËÙË͇ÌÚÌÓ Ï‡ÎÍÓ ÔÓ-‚ËÒÓ͇ ÒÚÓÈÌÓÒÚ ‚ ΄̇ÎÓ ÔÓÎÓÊÂÌË ‚ Ò‡‚ÌÂÌËÂ Ò ËÁÔ‡‚ÂÌÓÚÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ. ëÚÓÈ-


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Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡. ä‡ÍÚÓ Òڇ̇ flÒÌÓ, ÌÓχÎÌÓ Á‰‡‚ËÚ Îˈ‡ ÔË ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ÔÓ͇Á‚‡Ú ‡ÍÚË‚Ë‡Ì ̇ ÒËÏÔ‡ÚËÍÛÒ‡, ÍÓÂÚÓ ‚Ó‰Ë ‰Ó ÓÚÌÓÒËÚÂÎÌÓ Ì‡Ï‡Îfl‚‡Ì ÒÚÓÈÌÓÒÚËÚ ̇ ‚ÂÏ‚ËÚ ԇ‡ÏÂÚË / SDNN, RMSSD, NN50, pNN50, Variance/( Ôӂ˜ÂÚÓ ÓÚ Úflı Ò‡ ËÁ‡Á ̇ ‚‡„ÛÒÓ‚Ëfl ‚„ÂÚ‡ÚË‚ÂÌ ÍÓÌÚÓÎ). èË Ì‡¯ÂÚÓ ËÁÒΉ‚‡Ì ÔÓÎÛ˜‡‚‡Ï ӷ‡ÚÌÓÚÓ- ‚ ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ Ì‡ 2 ÚËÔ ‰Ë‡·ÂÚˈËÚ ÒÚÓÈÌÓÒÚËÚ ̇ ‚ÂÏ‚ËÚ ԇ‡ÏÂÚË Ò‡ ÔÓ-‚ËÒÓÍË ‚ Ò‡‚ÌÂÌËÂ Ò ÚÂÁË ‚ ΄̇ÎÓ ÔÓÎÓÊÂÌËÂ. íÓÁË ÂÁÛÎÚ‡Ú „Ó‚ÓË, ˜Â ÔË ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ·ÓÎÌËÚ ÓÚ 2 ÚËÔ Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÔÓ͇Á‚‡Ú ̇‰ÂÍ‚‡ÚÌÓ ‡ÍÚË‚Ë‡Ì ̇ ÒËÏÔ‡ÚËÍÛÒÓ‚Ëfl ÓÚ‰ÂΠ̇ ‚„ÂÚ‡Ú˂̇ڇ ÌÂ‚̇ ÒËÒÚÂχ Ë Â Ì‡Îˈ ÒËÏÔ‡ÚÓ-‚‡„‡ÎÂÌ ‰ËÒ·‡Î‡ÌÒ. íÓÁË Ì‡¯ ÂÁÛÎÚ‡Ú Ò˙‚Ô‡‰‡ Ò ‰‡ÌÌËÚÂ, ÔÓÎÛ˜ÂÌË ÓÚ ‰Û„Ë ËÁÒΉӂ‡ÚÂÎË / 2, 3 /. îË„Û‡ 2: ë‡‚ÌËÚÂÎÂÌ ‡Ì‡ÎËÁ ̇ ËÌÚÂ‚‡ÎÌËÚ ӈÂÌÍË ÔË Î„̇ÎÓ ÔÓÎÓÊÂÌËÂ Ë ÒΉ ÓÚÓÚÂÒÚ. ÌÓÒÚËÚ ̇ ÔÓ͇Á‡ÚÂÎfl çRVid Ò‡ ÔÓ˜ÚË Â‰Ì‡Í‚Ë ‚ ‰‚ÂÚ ÔÓÎÓÊÂÌËfl ̇ ÚflÎÓÚÓ ÔË ÓÚÓÚÂÒÚ‡. éÅëöÜÑÄçÖ ìÒÚ‡ÌÓ‚ÂÌÓ Â, ˜Â ‚Â΢Ë̇ڇ Ë Ù‡ÁÓ‚‡Ú‡ ı‡‡ÍÚÂËÒÚË͇ ̇ ‡‚ÚÓÌÓÏÌËÚ ÒÚËÏÛÎË Ò‡ Á‡‚ËÒËÏË ÓÚ ÔÓÎÓÊÂÌËÂÚÓ Ì‡ ÚflÎÓÚÓ /ıÓËÁÓÌÚ‡ÎÌÓ ÔÓ „˙· ËÎË Ô‡‚Ó ÔË ÔÓ‚Âʉ‡ÌÂÚÓ Ì‡ ÓÚÓÒÚ‡Ú˘ÌËfl ÚÂÒÚ/. èË Á‰‡‚ËÚ Îˈ‡ /̉ˇ·ÂÚˈËÚÂ/ ÌÓχÎÌÓ ‚ ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË ̇ ÚflÎÓÚÓ Ò ̇·Î˛‰‡‚‡ ÓÚÌÓÒËÚÂÎÌÓ Á‡ÒË΂‡Ì ̇ ÒËÏÔ‡ÚËÍÛÒÓ‚ËÚ ËÏÔÛÎÒË / 5 /. íÂÁË ‡‚ÚÓË Ò˙Á‰‡‚‡Ú ÏÓ‰ÂÎ, ÍÓÈÚÓ ÔÓ‰ÍÂÔfl Ô‰ÒÚ‡‚‡Ú‡, ˜Â ˜ÂÒÚÓÚ̇ڇ Á‡‚ËÒËÏÓÒÚ Ì‡ ‰Ëı‡ÚÂÎ̇ڇ ÒËÌÛÒÓ‚‡ ‡ËÚÏËfl  ÂÁÛÎÚ‡Ú ÓÚ ÔÓÏfl̇ڇ ‚ ÔÓÔÛÒ͇ÚÂÎÌËÚ ͇˜ÂÒÚ‚‡ ̇ ÒËÌÓ‡ÚˇÎÌËfl ‚˙ÁÂÎ ÔÓ‡‰Ë ËÌ‚ÂÒËflÚ‡, ÍÓflÚÓ Ì‡ÒÚ˙Ô‚‡ ‚˙‚ ‚‡„ÛÒÓ‚‡Ú‡ Ë ÒËÏÔ‡ÚËÍÛÒÓ‚‡Ú‡ ‡ÍÚË‚ÌÓÒÚ ÔÓ ‚ÂÏ ̇ ‰Ë¯‡ÌÂ. ë ‰Û„Ë ‰ÛÏË, ÔË ÎÂÍÓÒÚÂÔÂÌ̇ ÒËÏÔ‡ÚËÍÛÒÓ‚‡ ÒÚËÏÛ·ˆËfl ̇·Î˛‰‡‚‡ÌÓÚÓ Ì‡‡ÒÚ‚‡Ì ̇ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ ‚ÂÓflÚÌÓ Â Ò‚˙Á‡ÌÓ Ò Ì‡‡ÒÚ‚‡Ì ̇ ÌËÒÍÓ˜ÂÒÚÓÚ̇ڇ ÍÓÏÔÓÌÂÌÚ‡. èË ÔÓ-ËÌÚÂÌÁ˂̇ ÒËÏÔ‡ÚËÍÛÒÓ‚‡ ÒÚËÏÛ·ˆËfl ,Ó·‡˜Â, ̇‡ÒÚ‚‡ÌÂÚÓ Ì‡ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡ ‚ÂÓflÚÌÓ Â Ò‚˙Á‡ÌÓ Ò Ì‡Ï‡Îfl‚‡Ì ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇ Ò˙‰Â˜Ì‡Ú‡ ˜ÂÒÚÓÚ‡. åÌÓ„Ó ‰Û„Ë ÔËÏÂË Á‡ ÒËÏÔ‡ÚËÍÛÒÓ‚‡ ‡ÍÚË‚‡ˆËfl /ÚËÎÚ-ÚÂÒÚ, ÒÚÛ‰Ó‚ ÔÂÒÓÂÌ ÚÂÒÚ, ÔÒËı˘ÂÒÍË ÒÚÂÒ/ Ò‡ Ò‚˙Á‡ÌË Ò Ì‡‡ÒÚ‚‡Ì ̇ ÌËÒÍÓ˜ÂÒÚÓÚ̇ڇ ÍÓÏÔÓÌÂÌÚ‡ ̇ ‚‡ˇ·ËÎÌÓÒÚÚ‡ ̇

àáÇéÑà 1. èË ËÁÔ‡‚ÂÌÓ ÔÓÎÓÊÂÌË /‚ ÛÒÎÓ‚ËflÚ‡ ̇ ÓÚÓÒÚ‡Ú˘ÂÌ ÚÂÒÚ/ ·ÓÎÌËÚ ÓÚ 2 ÚËÔ Á‡ı‡ÂÌ ‰Ë‡·ÂÚ ÔÓ͇Á‚‡Ú ̇‰ÂÍ‚‡ÚÌÓ ‡ÍÚË‚Ë‡Ì ̇ ÒËÏÔ‡ÚËÍÛÒÓ‚Ëfl ÓÚ‰ÂΠ̇ ‚„ÂÚ‡Ú˂̇ڇ ÌÂ‚̇ ÒËÒÚÂχ. 2. ç‡Îˈ  ÒËÏÔ‡ÚÓ-‚‡„‡ÎÂÌ ‰ËÒ·‡Î‡ÌÒ. ãàíÖêÄíìêÄ 1. 2. 3. 4. 5. 6.

Seely, A., Macklem P. Complex systems and the technology of variability analysis. Clinical care, 2004, 8: R367-R384. Lewis, M. Heart rate variability Analysis: A Tool to assess Cardiac Autonomic Function. Computers, informatics, Nursing, 23, 2005, 6, 335-341. Kardelen, F., Akcurin, G., Ertug, H., et al. Heart rate variability and circadian variations in diabetes mellitus. Diabetes, 7, 2006, 1, 45-48. Toyry M. Kuopio Study. Diabetes, 45, 1996, 8, 308-315. Saul, J.P.,Berger, R.D., Albrecht P., et al. Transfer function analysis of the circulation: unique insights into cardiovascular regulation, Am J Physiol, 1991; 261:H1231-1245. Task Force of the European Society of Cardiology the North American Society of Pacing Electrophysiology, Heart Rate Variability : Standards of Measurement, Physiological Interpretation, and Clinical Use, Circulation, Mar 1996; 93: 1043 - 1065.

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: 1600 „. ëÓÙËfl ·ÛÎ.“ ÉÂÌ. ëÍÓ·Â΂“ 79 Ä åà-ñäÅ-åÇê éÚ‰ÂÎÂÌË ÔÓ ẨÓÍËÌÓÎÓ„Ëfl ‰- à‚‡Ì ÑÓÏÛҘ˂, ‰.Ï. ÏÓ·ËÎÂÌ ÚÂÎ.: 0887 69 52 35


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Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

93

éÔËÒ‡ÌË ̇ ÍÎËÌ˘ÂÌ ÒÎÛ˜‡È íêÖíàóÖç åÖçàçÉéÇÄëäìãÄêÖç çÖÇêéãìÖë å. äÎËÒÛÒÍË, ç.íÓÚ‚‡, å. чÒ͇ÎÓ‚, ñ. ñ‡ÌÍÓ‚‡ åÅÄã ◊ñ‡ˈ‡ âÓ‡Ì̇”, åì- ëÓÙËfl äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl SUMMARY We describe and illustrate our clinical observations and diagnostic experience in a case report of 42 year-old man presented with subacute bilateral pyramidal symptoms and left central hemiparesis. His MRI examination showed ischemic infarct in the right paramedial ventral pontine area due to a significant stenosis of the basilar artery. On the base of complex diagnostic work-up and after careful considering all differential diagnostic options for a stroke in young adulthood, a diagnosis of tertiary meningovascular neurolues was made. KEY WORDS: syphilis, neurolues, tertiary neurolues, meningovascular neurolues, stroke. êÖáûåÖ è‰ÒÚ‡‚ÂÌË Ò‡ ÍÎËÌ˘ÌËÚ ̇·Î˛‰ÂÌËfl Ë ‰Ë‡„ÌÓÒÚ˘ÌËflÚ ÓÔËÚ ÔË 42 „Ӊ˯ÂÌ ·ÓÎÂÌ Ò ÔÓ‰ÓÒÚÓ ‡Á‚ËÚË ̇ Í‚‡‰ËÔË‡ÏˉÂÌ ÒË̉ÓÏ Ë Î‚ÓÒÚ‡Ì̇ ˆÂÌÚ‡Î̇ ıÂÏËÔ‡ÂÁ‡ Ë åêí ‰‡ÌÌË Á‡ ÔÓÌÚËÌÂÌ ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ (àåà) ÔË ÒÚÂÌÓÁ‡ ̇ ·‡ÁË·̇ڇ ‡ÚÂËfl. Ç˙Á ÓÒÌÓ‚‡ ̇ ÍÓÏÔÎÂÍÒÌÓÚÓ ËÁÒΉ‚‡ÌÂ Ë ÛÚÓ˜ÌÂÌËÂÚÓ Ì‡ ‰ËÙÂÂ̈ˇÎÌÓ ‰Ë‡„ÌÓÒÚ˘ÌËÚ ‚˙ÁÏÓÊÌÓÒÚË Á‡ ‡ÚËÔ˘ÂÌ àåà ‚ Ï·‰‡ ‚˙Á‡ÒÚ ·Â ÔÓÒÚ‡‚Â̇ ‰Ë‡„ÌÓÁ‡Ú‡ - ÚÂÚ˘ÂÌ ÏÂÌËÌ„Ó‚‡ÒÍÛ·ÂÌ Ì‚ÓÎÛÂÒ. äãûóéÇà Ñìåà: Ì‚ÓÎÛÂÒ, ÚÂÚ˘ÂÌ ÒËÙËÎËÒ, ÏÂÌËÌ„Ó‚‡ÒÍÛÎaÂÌ Ì‚ÓÎÛÂÒ, ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ. ÇöÇÖÑÖçàÖ Ç Ò‚ÂÚÓ‚ÂÌ Ï‡˘‡· Ì‚ÓÒËÙËÎËÒ˙Ú (çë)  ¯ËÓÍÓ ‡ÁÔÓÒÚ‡ÌÂ̇ ËÌÙÂ͈Ëfl. èÂÁ ÔÓÒΉÌËÚ 15 „Ó‰ËÌË ‚ ·˙΄‡Ò͇ڇ Ì‚ÓÎӄ˘̇ ÎËÚÂ‡ÚÛ‡ Ì ҇ ÔÛ·ÎËÍÛ‚‡ÌË ÏÌÓ„Ó ÒÎÛ˜‡Ë Ò ÓÔËÒ‡ÌË ̇ Í˙ÒÌË Ì‚ÓÎӄ˘ÌË ÛÒÎÓÊÌÂÌËfl ̇ Ô‡ˆËÂÌÚË Ò ÎÛÂÚ˘̇ڇ ËÌÙÂ͈Ëfl. è‰ÒÚ‡‚flÏ ‰Ë‡„ÌÓÒÚ˘ÌËfl ÓÔËÚ Ë ÍÎËÌ˘ÌË Ì‡·Î˛‰ÂÌËfl ÔË ·ÓÎÂÌ Ò ÚÂÚ˘ÂÌ ÏÂÌËÌ„Ó‚‡ÒÍÛ·ÂÌ ÌÂ‚ÓÎÛÂÒ, ÔÓÚ˘‡˘ ͇ÚÓ ËÒıÂÏ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ. éèàëÄçàÖ çÄ ëãìóÄü ÄçÄåçÖáÄ 42 „Ӊ˯ÂÌ Ô‡ˆËÂÌÚ Ò ÓÔ·͂‡ ÓÚ Ú˙ÔË ·ÓÎÍË ‚ Í˙ÒÚ‡ Ë ËÁÚ˙Ô‚‡Ì ̇ ΂Ëfl, ‡ ÔÓ-Í˙ÒÌÓ Ì‡ ‰ÂÒÌËfl Í‡Í Ò ‰‡‚ÌÓÒÚ ÓÚ ‰‚‡ ÏÂÒˆ‡. àχΠÎÂÍË ÛË̇ÌË Ì‡Û¯ÂÌËfl Ò˙Ò ÒËÏÔÚÓÏË Ì‡ Á‡‰˙Ê͇ Ë ËÁÔÛÒ͇ÌÂ. ëΉ Ôӂ‰ÂÌÓÚÓ ‡Ï·Û·ÚÓÌÓ Î˜ÂÌËÂ Ë ÙËÁËÓÚÂ‡ÔËfl Á‡ “ÎÛÏ·Ó‡‰ËÍÛÎÂÂÌ ÒË̉ÓÏ”, ·ÓÎÍËÚ ËÁ˜ÂÁ̇ÎË, ÌÓ ËÁÚ˙Ô‚‡ÌÂÚÓ ‚ Í‡Í‡Ú‡ ÓÒڇ̇ÎÓ. Ñ‚‡ ‰Â̇ ÔÂ‰Ë ıÓÒÔËÚ‡ÎËÁ‡ˆËflÚ‡ ÛÒÂÚËÎ ËÁÚ˙Ô‚‡Ì ̇ Îfl‚‡Ú‡ ˙͇, ‰‚‡Ú‡ Í‡Í‡ Ë Îfl‚‡Ú‡ Îˈ‚‡ ÔÓÎÓ‚Ë̇, ͇ÍÚÓ Ò‚ÂÚÓ‚˙ÚÂÊ Ë Á‡ÎËÚ‡ÌÂ. á‡ÔӘ̇ΠΘÂÌËÂ Ò Í‡‚ËÌÚÓÌ, ·ÂÚ‡ÒÂÍ Ë ÏË΄‡Ï‡. ç‡ ÚÂÚËfl ‰ÂÌ Ò··ÓÒÚÚ‡ ÏÛ ‚ ΂ËÚ Í‡ÈÌËˈ Òڇ̇· ÚÂÊ͇, ‰Ó ÒÚÂÔÂÌ Ô‡ˆËÂÌÚ˙Ú ‰‡ Ì ÏÓÊ ‰‡ ıÓ‰Ë Ò‡Ï. åàçÄãà áÄÅéãüÇÄçàü ãÂÍÛ‚‡Ì Á‡ flÁ‚‡ ̇ ‰ÛÓ‰ÂÌÛχ; ÔÂ‰Ë ÌflÍÓÎÍÓ ÏÂÒˆ‡, ·ÎËÁÍËÚ ÓÔËÒ‚‡Ú ÔËÔ‡‰˙˜ÌË Ò˙ÒÚÓflÌËfl, Á‡ ÍÓËÚÓ Â ÔÓ‚ÂÎ ÍÓÌÒÛÎÚ‡ˆËfl Ë äí ̇ „·‚‡, ·ÂÁ ‰‡ ·˙‰Â ÛÚÓ˜ÌÂ̇ Ìfl͇͂‡ Ô˘Ë̇.

ëéåÄíàóçàüí ëíÄíìë ç ÔÓ͇Á‚‡ Ô‡ÚÓÎӄ˘ÌË Ì‡ıÓ‰ÍË, ÓÒ‚ÂÌ Ò·· 3/6 ÒËÒÚÓ΢ÂÌ ¯ÛÏ Ì‡ Ò˙‰Â˜ÌËfl ‚˙ı Ë ÔÛÌÍÚ‡ ̇ Ö·-ÅÓÚÍËÌ. çÖÇêéãéÉàóÖç ëíÄíìë èêà èéëíöèÇÄçÖíé ãËÔÒ‚‡ ëåêÑ. áÂÌˈËÚ ҇ ‰̇͂Ë, Í˙„ÎË, Ò‰ÌÓ ¯ËÓÍË, Ò˙Ò Á‡Ô‡ÁÂ̇, ÌÓ Ïۉ̇ Ôfl͇ Ë ÍÓÌÒÂÒÛ‡Î̇ ‡͈Ëfl ̇ Ò‚ÂÚÎË̇. á‡Ô‡ÁÂ̇ ÁÂÌ˘̇ ‡͈Ëfl ÔË ‡ÍÓÏÓ‰‡ˆËfl Ë ÍÓÌ‚Â„Â̈Ëfl. ã‚ÓÒÚ‡Ì̇ ˆÂÌÚ‡Î̇ ÎÂÁËfl ̇ 7-ÏË Ë 12ÚË óåç. ÑËÁ‡Ú˘ÂÌ „Ó‚Ó. 䂇‰ËÔË‡ÏˉÂÌ ÒË̉ÓÏ, Ò Î‚ÓÒÚ‡Ì̇ ˆÂÌÚ‡Î̇ ıÂÏËÔ‡ÂÁ‡ (ååí 2/5). ëËÏÂÚ˘ÌÓ ÒÔ‡ÒÚ˘ÌÓ Ôӂ˯ÂÌ ÏÛÒÍÛÎÂÌ ÚÓÌÛÒ ‚ ˜ÂÚËËÚ Í‡ÈÌË͇, ÔÓ-ËÁ‡ÁÂÌ Á‡ ΂Ëfl Í‡Í. ÅÓÎÂÒÚÌÓ ÓÊË‚ÂÌË ÂÙÎÂÍÒË, ÔÓ-ËÁ‡ÁÂÌË ‚ Îfl‚Ó, ‰‚ÛÒÚ‡Ì̇ ÍÓÂÏ̇ ‡ÂÙÎÂÍÒËfl, ÍÎÓÌÛÒË Ì‡ ÒÚ˙ԇ·ڇ, ÌÂËÁ˜ÂÔ‡˘ Ò ‚ ‰flÒÌÓ. ëËÏÔÚÓÏË Ì‡ Ň·ËÌÒÍË ÔÓÎÓÊËÚÂÎÂÌ ‰‚ÛÒÚ‡ÌÌÓ. ÅÓÎÌËflÚ ËÁ‚˙¯‚‡ ÍÓÓ‰Ë̇ˆËÓÌÌËÚ ÔÓ·Ë Ò ‰ÂÒÌËÚ Í‡ÈÌËˆË ·ÂÁ ÓÒÓ·ÂÌÓÒÚË. á‡Ô‡ÁÂ̇ ÂÍÒÚ‡ÎÂÏÌËÒÍÓ‚‡Ú‡ ÒÂÚË‚ÌÓÒÚ. ëÏÛÚÂÌ ÎÂÍÓ ‰‚ÛÏÂÌÓ ÔÓÒÚ‡ÌÒÚ‚ÂÌ, ‚Ë·‡ˆËÓÌÂÌ Ë ÒÚ‡‚ÌÓ-ÏÛÒÍÛÎÂÌ ÛÒÂÚ Á‡ Í‡Í‡Ú‡. íê ÍÓÌÚÓÎË‡ Ò‚Ó·Ó‰ÌÓ. Çäî: Ô‡ˆËÂÌÚ˙Ú Ìflχ ‡Ù‡ÁËfl, ‡Ô‡ÍÒËfl ËÎË ‡„ÌÓÁËfl, ÔË ÎÂÍÓ Á‡·‡‚ÂÌ ÏËÒÎÓ‚ÂÌ ÔÓˆÂÒ, ÔÓ-Ò··‡ ÍËÚ˘ÌÓÒÚ Ë ‰ËÒÍÂÚÌË Ô‡ÏÂÚÓ‚Ë ÒÏÛ˘ÂÌËfl. ååSE – 27 Ú. àáëãÖÑÇÄçàü à äéçëìãíÄñàà èää Ë ·ËÓıËÏ˘ÌËÚ ÔÓ·Ë Ì ÔÓ͇Á‚‡Ú ÍÎËÌ˘ÌÓ Á̇˜ËÏË Ô‡ÚÓÎӄ˘ÌË ÔÓÏÂÌË. é˜ÌËÚ ‰˙̇ Ò‡ Ò ‚ËÚ‡ÎÌË Ô‡ÔËÎË, ̇ ÌË‚ÓÚÓ Ì‡ ÂÚË̇ڇ, Ò ÎÂ͇ ÚÂÏÔÓ‡Î̇ ·Î‰ÓÒÚ. êÂÌÚ„ÂÌÓ‚‡Ú‡ „‡ÙËfl ̇ ·ÂÎËfl ‰Ó· Ë Ò˙ˆÂ  ‚ ÌÓχ. äí ̇ ÏÓÁ˙˜ÂÌ Ô‡ÂÌıËÏ, ‚ÂÌÚËÍÛÎË Ë ·‡Á‡ÎÌË ˆËÒÚÂÌË - ‚ ÌÓχ. å‡ÒÚÂÌ ÔÓÙËÎ Ò ıËÔÓ-ıÓÎÂÒÚÂÓÎ-ÎËÔÓÔÓÚÂËÌÂÏËfl. ÖÖÉ - ÌËÒÍÓ Ë Ò‰ÌÓ ‚ÓÎÚ‡Ê̇ ‰ÂÁÓ„‡ÌËÁË‡Ì‡ ÓÒÌӂ̇ ‡ÍÚË‚ÌÓÒÚ ÓÚ ·ÂÚ‡ ‚˙ÎÌË, ËÌÚÂÏËÚÂÌÚÌÓ ‰ËÙÛÁÌË ‰ÂÎÚ‡ 5-7 ÒÂÍ, ‰ËÒÍÂÚÌË ‰ËÙÛÁÌË ÌÂÒÔˆËÙ˘ÌË ÔÓÏÂÌË. åêí ̇ „·‚ÂÌ ÏÓÁ˙Í ÔÓ͇Á‚‡ ËÌÚ‡‡ÍÒˇÎ̇ ËÌÙ‡ÚÂÌÚÓˇÎ̇ ıËÔÂËÌÚÂÌÁ̇ ‚ í2 Ë FLAIR ËÁÏÂ‚‡ÌËflÚ‡ ÎÂÁËfl ‚ ÔÓÌÒ‡ Ô‡‡Ï‰ˇÌÌÓ ‚ ‰flÒÌÓ, ‰ÓÒÚË„‡˘‡ ‰Ó ÔÓ‚˙ıÌÓÒÚÚ‡ ̇ ÔÓÌÒ‡ ‚ÂÌÚ‡ÎÌÓ Ë ‰ÓÁ‡ÎÌÓ ‰Ó ÔÓÌÚËÌÌËfl Ú„ÏÂÌÚÛÏ (îË„ÛË 1, 2). íÂËÚÓˇÎÂÌ Ô‡‡Ï‰ˇÌÂÌ ÔÓÌÚËÌÂÌ ËÌÙ‡ÍÚ. ç Î˘‡Ú ‰Û„Ë Ó„ÌˢÌË ÎÂÁËË ‚ ÏÓÁ˙˜ÌËfl Ô‡ÂÌıËÏ. ÇÂÌÚËÍÛÎ̇ ÒËÒÚÂχ, ·‡Á‡ÎÌË ˆËÒÚÂÌË Ë ÒÛ·‡‡ıÌÓˉÌË ÔÓÒÚ‡ÌÒÚ‚‡ ÔÓ ÍÓÌ‚ÂÍÒËÚÂÚ‡ ‚ ÌÓχ. á̇˜Ëχ ‰Û͈Ëfl ̇ Í˙‚ÓÚÓ͇ ÔÓ ıÓ‰‡ ̇ ‡ÚÂËfl ·‡ÁË·ËÒ ‰ËÒÚ‡Î̇ڇ È ÚÂÚ‡ (‚ËÒÓÍÓÒÚÂÔÂÌ̇ ÒÚÂÌÓÁ‡), ͇ÍÚÓ Ë ÔÓÍÒËχÎÌÓ, ÌÂÔÓÒ‰ÒÚ‚ÂÌÓ ÒΉ ÙÓÏË‡ÌÂÚÓ Ë ÓÚ ‰‚ÂÚ ‚ÂÚ·‡ÎÌË ‡ÂÚËË (îË„Û‡ 3). ÖÍÒÚ‡Í‡ÌˇÎ̇ڇ ÑÓÔÎÂÓ‚‡ ÒÓÌÓ„‡ÙËfl ‰ÂÏÓÌÒÚË‡ ÌÓχÎ̇ ıÂÏÓ‰Ë̇Ï˘̇ ̇ıӉ͇. í‡ÌÒÍ‡ÌˇÎÌÓ - ‡ÒËÏÂÚËfl ‚ Í˙‚ÓÚÓ͇ ̇ ‰‚ÂÚ Ò‰ÌË ÏÓÁ˙˜ÌË ‡ÚÂËË (ëåÄ), ÔË ÎÂÍÓ Ôӂ˯ÂÌË ÒËÒÚÓÎÌË Ë Ò‰ÌË ÒÍÓÓÒÚË Á‡ ‰flÒ̇ ëåÄ ‰Ó 140/107 ÒÏ/ÒÂÍ Ë Îfl‚‡ Ô‰̇ ÏÓÁ˙˜Ì‡ ‡ÚËËfl (èåÄ) Ò ÚÛ·ÓÎÂÌÚÌÓÒÚ Ë ‰ÓÔ˙ÎÌËÚÂÎÌË ¯ÛÏÓ‚Â. ÄÚÂËfl ·‡ÁË·ËÒ (ÄÅ) ̇ ‰˙ηӘË̇ 9597 ÏÏ Ëχ ÒÍÓÓÒÚË ‰Ó 170/110 ÒÏ/Ò - ‰‡ÌÌË Á‡ ıÂÏÓ‰Ë-


Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

‡ÔËÎ, 2007

94

îË„Û‡ 3.

îË„Û‡ 1. ̇˜ÌÓ Á̇˜Ëχ ÒÚÂÌÓÁ‡ ̇ ÄÅ (60-75%), ‚ Ò˙ÓÚ‚ÂÚÒÚ‚ËÂ Ò ‰‡ÌÌËÚ ÓÚ åêí. äÓÌÒÛÎÚ‡ˆËfl Ò Í‡‰ËÓÎÓ„ - ‰‡ÌÌË Á‡ àÅë, ‚ÂÓflÚÂÌ ÔÂÊË‚flÌ ÏËÓ͇‰ÂÌ ËÌÙ‡ÍÚ, ÖäÉ Ò ÍÓÓ̇ÌË í-‚˙ÎÌË ‚ 2-Ó, 3-ÚÓ Ë aVF ÓÚ‚Âʉ‡ÌËfl. ÖıÓ͇‰ËÓ„‡ÙËflÚ‡ ÔÓ͇Á‡ ÛÏÂÂ̇ ‡ÓÚ̇ „Û„ËÚ‡ˆËfl, Á‡Ô‡ÁÂ̇ ÒËÒÚÓÎ̇ Ë ‰Ë‡ÒÚÓÎ̇ ‡ÁÏÂË. îà – 51%. ãËÍ‚Ó˙Ú ÔË Ì‡Ô‡‚Â̇ڇ ÎÛÏ·‡Î̇ ÔÛÌ͈Ëfl  ·ËÒÚ˙, ·ÂÁˆ‚ÂÚÂÌ. ã‚ÍÓˆËÚË 592/3; ÂËÚÓˆËÚË 1.536/3; è‡Ì‰Ë /++++/; ÍÓ΢ÂÒÚ‚Ó ·ÂÎÚ˙Í 152.1 Ï„%; Á‡ı‡ 2,4 ÏÏÓÎ/Î; ıÎÓ 94 ÏÏÓÎ/Î; ÑËÙÂÂÌˈ‡ÎÌÓ ·ÓÂÌÂ Ò Ly 75%, Mo 12%, Pl 5%, Sg 7%, Ret 1%; åËÍÓ·ËÓÎӄ˘ÌÓÚÓ Ë ‚ËÛÒÓÎӄ˘ÌÓ ËÁÒΉ‚‡Ì ̇ ÎËÍ‚Ó - Ì„‡ÚË‚ÌË. HIV ÓÚˈ‡ÚÂÎÂÌ. ëÂÛÏÂÌ ÏËÍÓÚÂÒÚ Á‡ ÎÛÂÒ VDRL (+++). àÁÒΉ‚‡ÌËflÚ‡ ̇ ÎËÍ‚Ó Á‡ ÒÔˆËÙ˘ÌË Ë ÌÂÒÔˆËÙ˘ÌË ÔÓ·Ë Á‡ ÒËÙËÎËÒ VDRL (+++) Ë TPHA (++++) Ò‡ ÒËÎÌÓ ÔÓÎÓÊËÚÂÎÌË. äÓÌÒÛÎÚ‡ˆËfl Ò ‰ÂχÚÓÎÓ„ Ë ËÌÙÂ͈ËÓÌËÒÚ - ÂÁÛÎÚ‡ÚËÚ ÓÚ ‰‚‡Ú‡ ‚ˉ‡ ÒÂÓÎӄ˘ÌË Ë ÎËÍ‚ÓÓÎӄ˘ÌË ÚÂÒÚÓ‚Â Ò‡ ÒËÎÌÓ ÔÓÎÓÊËÚÂÎÌË Ë Í‡Ú„Ó˘ÌÓ ÔÓÚ‚˙ʉ‡‚‡Ú ‰Ë‡„ÌÓÁ‡Ú‡ Ì‚ÓÒËÙËÎËÒ - Í˙ÒÂÌ ÎÛÂÚ˘ÂÌ ÏÂÌËÌ„ÓÂ̈ÂÙ‡ÎËÚ Ë ÚÂÚ˘ÂÌ ‚‡ÒÍÛ·ÂÌ Ì‚ÓÎÛÂÒ. èӂ‰ÂÌÓ ·Â¯Â ΘÂÌËÂ Ò penicillin G 24 ÏËÎËÓ̇ IU,

îË„Û‡ 2.

‚ÂÌÓÁÌÓ Á‡ 14 ‰ÌË, ‚ÎË‚‡ÌËfl, ‰ÂÍÒ‡ÏÂÚ‡ÁÓÌ, ͇‚ËÌÚÓÌ, Á‡ÌÚ‡Í, ÔÂÌÚÓÍÒËÙËÎËÌ, ‡ÒÔËËÌ Ë Âı‡·ËÎËÚ‡ˆËfl. èË ÍÓÌÚÓÎÌÓÚÓ ÎËÍ‚ÓÌÓ ËÁÒΉ‚‡Ì Ëχ¯Â ΂ÍÓˆËÚË 144/3, ÂËÚÓ 296/3, è‡Ì‰Ë (+++), ·ÂÎÚ˙Í 123,4 Ï„%, ÓÍÒËıÂÏÓ„ÎÓ·ËÌ 1,24 Ö, ·ËÎËÛ·ËÌ 1,99 Ö, Á‡ı‡ 1,7 ÏÏÓÎ/Î; ıÎÓ 124 ÏÏÓÎ/Î. ÑËÙÂÂÌˈ‡ÎÌÓ ·ÓÂÌÂ: Ly 84%, Mo 15%, Pl 1%. 臈ËÂÌÚ˙Ú ·Â¯Â ̇ÒÓ˜ÂÌ Í˙Ï ÍÓÊÌÓ-‚ÂÌÂÓÎӄ˘ÂÌ ‰ËÒÔ‡ÌÒÂ Á‡ ‰ËÒÔ‡ÌÒÂËÁ‡ˆËfl Ë ÔÓ-̇ڇÚ˙¯ÌÓ Î˜ÂÌËÂ Ò ·ÂÌÁËÎÔÂÌˈËÎËÌ ÂÊÂÒ‰Ï˘ÌÓ Ë Á‡ ·‡ÎÌÂÓ҇̇ÚÓˇÎÌÓ Î˜ÂÌËÂ Ë Âı‡·ËÎËÚ‡ˆËfl ̇ ‰‚Ë„‡ÚÂÎÌËfl ‰ÂÙˈËÚ. Ç ÎËÍ‚Ó‡ ̇ ÚÂÚËfl ÏÂÒˆ Ëχ¯Â 24/3 ΂ÍÓˆËÚË Ë 123,4 Ï„% ·ÂÎÚ˙Í. éÅëöÜÑÄçÖ íÂÏËÌ˙Ú çë ‚Íβ˜‚‡ ¯ÂÒÚ ÒË̉Óχ: 1.ÄÒËÏÔÚÓÏÂÌ çë; 2. éÒÚ˙ ÒËÏÔÚÓχÚ˘ÂÌ ÒËÙËÎËÚ˘ÂÌ ÏÂÌËÌ„ËÚ; 3.åÂÌËÌ„Ó‚‡ÒÍÛÎËÚ; 4.è‡ÂÌıËÏÂÌ çë (ÔÓ„ÂÒ˂̇ Ô‡‡ÎËÁ‡ Ë Ú‡·ÂÒ ‰ÓÁ‡ÎËÒ); 5.ÉÛÏÓÁÂÌ çë; 6.ÇÓ‰ÂÌ ÒËÙËÎËÒ (6). èÓ‡‰Ë ÚÓ‚‡ ‡ÁÌÓÓ·‡ÁË ̇ ÍÎËÌ˘̇ ËÁfl‚‡ çë  ̇˘‡Ì ◊‚ÂÎËÍËflÚ ËÏËÚ‡ÚÓ”. èÓ̇ÒÚÓfl˘ÂÏ Ì‡Èӷ˘‡ÈÌËÚ ÙÓÏË Ì‡ çë Ò‡ ‡ÒËÏÔÚÓÏÌËÚÂ, ÏÂÌË̄‡ÎÌËÚÂ Ë Ò˙‰Ó‚ËÚÂ. óÂÒÚÓ ÏÂÌËÌ„ËÚÂ Ë ÏÓÁ˙˜ÌËÚ Ò˙‰Ó‚ ҇ Á‡Ò„̇ÚË Á‡Â‰ÌÓ Ë ÚÓ‚‡ Ò ÓÁ̇˜‡‚‡ Ò ÚÂÏË̇ ÏÂÌËÌ„Ó‚‡ÒÍÛ·ÂÌ ÒËÙËÎËÒ. ä·ÒËÙË͇ˆËflÚ‡ ̇ çë ˜ÂÒÚÓ Â Ó·‚˙Á‚‡Ì‡ Ò ÍÓ̈ÂÔˆËflÚ‡ Á‡ ÍÎËÌ˘ÌËÚ ËÁfl‚Ë Ì‡ Ò˙ÒÚÓflÌËÂÚÓ ‚ Á‡‚ËÒËÏÓÒÚ ÓÚ ‚ÂÏÂÚÓ Ì‡ Úflı̇ڇ ÔÓfl‚‡. ç‡ÔËÏÂ ÒË̉ÓÏËÚ ̇ ÏÂÌË̄‡ÎÂÌ, ÏÂÌËÌ„Ó‚‡ÒÍÛ·ÂÌ ÒËÙËÎËÒ, ÔÓ„ÂÒ˂̇ Ô‡‡ÎËÁ‡ Ë Ú‡·ÂÒ ‰ÓÁ‡ÎËÒ Ò‡ Ò‚˙Á‡ÌË Ò˙Ò ÒÓ͇ Úflı̇ڇ ÔÓfl‚‡ ÒΉ ̇˜‡Î̇ڇ ËÌÙÂ͈Ëfl – ÂÒÔÂÍÚË‚ÌÓ ÌflÍÓÎÍÓ ÏÂÒˆ‡, 5, 10 Ë 15-20 „Ó‰ËÌË. çÓ Ò„‡ åêí ‰ÓÔË̇Òfl Á‡ ÔÓ-ÔˆËÁ̇ ‡Ì‡ÚÓÏ˘̇ ‰Ë‡„ÌÓÁ‡ Ë çë ̇È-‰Ó· Ò Í·ÒËÙˈË‡ ˜ÂÁ ‰ÓÏËÌË‡˘Ëfl ÍÎËÌ˘ÂÌ ‰ÂÙˈËÚ. íÓÁË ÏÂÚÓ‰ ̇ Í·ÒËÙË͇ˆËfl ‚Íβ˜‚‡ ÚÂÏËÌË Í‡ÚÓ çë Ò „˙·Ì‡˜ÌÓ-ÏÓÁ˙˜Ì‡ Û‚‰‡, çë Ò Û‚‰‡ ̇ ˜ÂÂÔÌÓ – ÏÓÁ˙˜ÌË ÌÂ‚Ë (óåç), çë Ò ËÌÒÛÎÚ, çë Ò ÔËÔ‡‰˙ˆË, çë Ò ‰ÂÏÂ̈Ëfl.(11) ç‚ÓËÁÓ·‡Áfl‚‡˘ËÚ ÏÂÚÓ‰Ë Ì ‰‡‚‡Ú ÒÔˆËÙ˘ÌË ‰‡ÌÌË ÔË çë. èÓÎÂÚ‡ ̇ ÔÓÌËÊÂ̇ ÔÎ˙ÚÌÓÒÚ ÔË äí ̇ „·‚ÂÌ ÏÓÁ˙Í ÓÚ„Ó‚‡flÚ Ì‡ ËÒıÂÏ˘ÌË ËÌÙ‡ÍÚË ‚ Ò˙ÓÚ‚ÂÚÌËÚ Ò˙‰Ó‚Ë ÚÂËÚÓËË. èË ·ÓÎÌËfl,ÓÔËÒ‡Ì ÓÚ Ì‡Ò, ‚˙ÔÂÍË ˜Â Ì Ò ͇҇¯ Á‡ ‡ÌÌÓ ÔÓ‚Âʉ‡Ì ̇ ËÁÒΉ‚‡ÌÂÚÓ Ë ‚ÂÓflÚÌÓ ÔÓ‡‰Ë ÒÚ‚ÓÎÓ‚‡Ú‡ ÎÓ͇ÎËÁ‡ˆËfl ̇ ÎÂÁËflÚ‡, ÓÚÍÎÓÌÂÌËfl Ì ·flı‡ ÛÒÚ‡ÌÓ‚ÂÌË. ë ӄΉ ̇ ÚÓ‚‡, ͇ÍÚÓ Ë ÔÓ‡‰Ë Ú·Ò˙˜ÌËfl ıÓ‰ ̇ Á‡·ÓÎfl‚‡ÌÂÚÓ Ò ‚ÂÓflÚÌË ‰‚ ËÎË Ôӂ˜ ӄÌˢ‡ ̇ Û‚‰‡, Í‚‡‰ËÔË‡ÏˉÌËfl ÒË̉ÓÏ, ÏÂıÛÌËÚ ̇Û¯ÂÌËfl Ë ÚÂÏÔÓ‡Î̇ڇ ·Î‰ӂ‡ÚÓÒÚ Ì‡ Ô‡ÔËÎËÚÂ, ̇ Ô˙‚Ó ÏflÒÚÓ ÔË Ô‡ˆËÂÌÚ‡ Ò ӷÒ˙‰Ë ‚˙ÁÏÓÊÌÓÒÚÚ‡ Á‡ ÏÌÓÊÂÒÚ‚Â̇ ÒÍÎÂÓÁ‡. ëΉ


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

ÔÓ‚Âʉ‡ÌÂÚÓ Ì‡ åêí, ‚Íβ˜ËÚÂÎÌÓ åê ‡Ì„ËÓ„‡ÙËfl, Ú‡ÁË ‰Ë‡„ÌÓÁ‡ ·Â¯Â ÓÚı‚˙ÎÂ̇. чÌÌËÚ Á‡ ÒÚ‚ÓÎÓ‚ ÔÓÌÚËÌÂÌ ËÌÙ‡ÍÚ Ë ÒÚÂÌÓÁ‡ ̇ ·‡ÁË·̇ڇ ‡ÚÂËfl ̇ÒÓ˜Ëı‡ ‰Ë‡„ÌÓÒÚ˘ÌÓÚÓ ÏËÒÎÂÌ Í˙Ï ËÁflÒÌfl‚‡Ì ̇ ÌÂÍÓÌ‚Â̈ËÓ̇ÎÌË ËÒÍÓ‚Ë Ù‡ÍÚÓË ÔË Ï·‰ Ô‡ˆËÂÌÚ Ò ‡ÚËÔ˘ÂÌ ÏÓÁ˙˜ÂÌ ËÌÒÛÎÚ. íÑë ÔÓ͇Á‡ ÒÚÂÌÓÚ˘ÌË ÔÓÏÂÌË Ì ҇ÏÓ ‚ Í˙‚ÓÚÓ͇ ̇ ÄÅ, ÌÓ Ï‡Í‡ Ë ‚ ÔÓ-χÎ͇ ÒÚÂÔÂÌ Á‡ Îfl‚‡ èåÄ Ë ‰flÒ̇ ëåÄ. í‡ÁË ıÂÏÓ‰Ë̇Ï˘̇ ̇ıӉ͇ ·Â¯Â ÓÒÌÓ‚‡ÌË ‰‡ Ò ÏËÒÎË Á‡ ‰ËÙÛÁÂÌ Ò˙‰Ó‚ ÔÓˆÂÒ, ‡Ì„‡ÊË‡˘ ·‡Á‡ÎÌËÚ ÏÓÁ˙˜ÌË ‡ÚÂËË, ͇ÍÚÓ Ò ÓÔËÒ‚‡ ÔË ‚˙ÁÔ‡ÎËÚÂÎÌË ÔÓˆÂÒË (12, 13) èË ÔÓ-ÔÓ‰Ó·ÌÓ ‡ÁÔËÚ‚‡Ì ̇ Ô‡ˆËÂÌÚ‡ Ò Ó͇Á‡, ˜Â ÔÂ‰Ë 15 „Ó‰ËÌË ·ÓÎÌËflÚ ·ËÎ “Á‡‡ÁÂÌ ÓÚ ÊÂ̇ Ë ÎÂÍÛ‚‡Ì Ò ‡ÌÚË·ËÓÚˈ˔, ÌÓ Ì ÏÓʯ ‰‡ ̇ÁÓ‚Â ‰Ë‡„ÌÓÁ‡. íÓ‚‡ ‰Ó‚‰ ‰Ó ÔÓ‚Âʉ‡Ì ̇ ÎÛÏ·‡Î̇ ÔÛÌ͈Ëfl Ë ÒÂÓÎӄ˘ÌË ÔÓ·Ë Á‡ ÒËÙËÎËÒ. ãËÍ‚ÓÌËflÚ ÒË̉ÓÏ ÔË çë  Ô‰ÒÚ‡‚ÂÌ ÓÚ ÎËÏÙÓˆËÚ̇ ÔÎÂÓˆËÚÓÁ‡ (‰Ó 400 ÍÎÂÚÍË/ ÍÛ·. ÏÏ), ıËÔÂÔÓÚÂËÌÓ‡ıËfl (‰Ó 100-200 Ï„/‰Î), Ôӂ˯ÂÌË „‡Ï‡ „ÎÓ·ÛÎËÌË, Ôӂ˯ÂÌÓ ÓÚÌÓ¯ÂÌË Ig G/Ó·˘ ·ÂÎÚ˙Í, ÌÓχÎ̇ „βÍÓÁ‡, ÔÓÎÓÊËÚÂÎÌË ÒÂÓÎӄ˘ÌË ÔÓ·Ë. èÓ‰Ó·ÌË ÔÓÏÂÌË ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ÛÒÚ‡ÌÓ‚ÂÌË Ó˘Â ÔË ‚ÚÓ˘ÌËfl ÒËÙËÎËÒ (3), ÎËÍ‚Ó˙Ú Â ‚‡ˇ·ËÎÌÓ ‡ÍÚË‚ÂÌ ÔÂÁ ‚Ò˘ÍË ÒÚ‡‰ËË Ì‡ ·ÓÎÂÒÚÚ‡ Ò ÚẨÂ̈Ëfl Í˙Ï ÌÓχ ÔË Ì‡Ô‰̇ÎË, Í˙ÒÌÓ ÔÂÒËÒÚË‡˘Ë ÒÎÛ˜‡Ë (5). ç Ò˙˘ÂÒÚ‚Û‚‡ ‰Û„‡ ·ÓÎÂÒÚ, ÍÓflÚÓ ‰‡ ÓÔË΢‡‚‡ ÚÓÎÍÓ‚‡ ÊË‚Ó ÂÙÂÍÚËÚ ̇ ıÓÌ˘ÌËfl ÔÓÒÚÓflÌÌÓ ‡ÍÚË‚ÂÌ ˆÂ·ÓÒÔË̇ÎÂÌ ÏÂÌËÌ„ËÚ (14). ëÂÓÎӄ˘̇ڇ ‰Ë‡„ÌÓÁ‡ ̇ ÒËÙËÎËÒ‡ Á‡‚ËÒË ÓÚ ‰ÂÏÓÌÒÚ‡ˆËflÚ‡ ̇ ‰ËÌ ÓÚ ‰‚‡Ú‡ ‡ÌÚËÚ· - ÌÂÒÔˆËÙ˘ÌË (ÌÂÚÂÔÓÌÂÏÌË) Ë ÒÔˆËÙ˘ÌË (ÚÂÔÓÌÂÏÌË). ä˙Ï ÌÂÒÔˆËÙ˘ÌËÚ ÚÂÒÚÓ‚Â Ò ÓÚ̇ÒflÚ ÚÂÁË Ì‡ Wassermann, ÔˆËÔËÚ‡ˆËÓÌÌËÚ ÚÂÒÚÓ‚Â VDRL (Venereal Disease Research Laboratory), RPR (Rapid Plasma Reagin). ä˙Ï Ì‡È-ËÁÔÓÎÁ‚‡ÌËÚ ÒÔˆËÙ˘ÌËÚ ÒÂÓÎӄ˘ÌË ‡͈ËË ÒÔ‡‰‡ ÚÂÒÚ˙Ú Á‡ ËÏÓ·ËÎËÁ‡ˆËfl ̇ ·Î‰‡Ú‡ ÚÂÔÓÌÂχ –TPI (Treponema Pallidum Immobilisation). íÓÁË ÚÂÒÚ Â ËÁ‚ÂÒÚÂÌ Ó˘Â Í‡ÚÓ ‡͈Ëfl ̇ Nelson-Mayer. ÑÛ„Ë ÒÔˆËÙ˘ÌË ÚÂÒÚÓ‚Â Ò‡ ÙÎÛÓÂÒˆÂÌÚÌËfl (FTA, FTA-Abs-Fluorescent Treponemal Antibody Absorbtion) Ë TPHA (Treponema Pallidum Haemagglutination Assay). ÇËÒÓ͇ ÒÚÂÔÂÌ Ì‡ ÒÔˆËÙ˘ÌÓÒÚ Ëχ ÚÂÒÚ˙Ú 19S/IgM/FTA-Abs (1). Ñˇ„ÌÓÁ‡Ú‡ ̇ çë ÓÒÚ‡‚‡ ÚÛ‰ÂÌ ÔÓ·ÎÂÏ Ë ‰ÓÒ„‡. èËÂÚÓ Â, ˜Â ÔÓÎÓÊËÚÂÎÌËflÚ ÚÂÒÚ VDRL ‚ ÎËÍ‚Ó‡  ‰ÓÒÚ‡Ú˙˜ÂÌ Á‡ ‰Ë‡„ÌÓÁ‡Ú‡. ë˙˘ÂÒÚ‚Û‚‡Ú Ó·‡˜Â ÒÎÛ˜‡Ë Ò Ù‡Î¯Ë‚Ó ÔÓÎÓÊËÚÂÎÌË ÂÁÛÎÚ‡ÚË, ͇ÍÚÓ Ë ‚˙ÁÏÓÊÌÓÒÚ ‰‡ Ëχ ·ÓÎÂÒÚ ÔË Ì„‡Ú˂̇ ÒÂÓÎӄ˘̇ ‡͈Ëfl. èÓ ÓÚÌÓ¯ÂÌË ̇ ÚÓ‚‡ Í‡Í‚Ó ÚÓ˜ÌÓ Ò Ô‡‚Ë Á‡ ÒË„Û̇ ÒÂÓÎӄ˘̇ ‰Ë‡„ÌÓÁ‡ Ìflχ Á·ÚÂÌ Òڇ̉‡Ú Ë ÍÎËÌ˘̇ڇ ÌÂÒË„ÛÌÓÒÚ ÔÓ‰˙Îʇ‚‡ ‰‡ Ò˙˘ÂÒÚ‚Û‚‡. Ç˙ÔÂÍË ÚÓ‚‡ ÔÓÎÓÊËÚÂÎÌËÚ ÒÔˆËÙ˘ÌË ÚÂÒÚÓ‚Â, Ë Ì‡È-‚˜ FTA, ‚ ÎËÍ‚Ó‡ ÏÓ„‡Ú ‰‡ Ò ÔËÂÏ‡Ú Í‡ÚÓ ÒÂÓÎӄ˘ÌÓ ‰Ó͇Á‡ÚÂÎÒÚ‚Ó Á‡ çë (1). èË ÓÔËÒ‡ÌËfl ÓÚ Ì‡Ò ÒÎÛ˜‡È Ëχ ÒËÎÌÓ ÔÓÎÓÊËÚÂÎÌË VDRL (‚ ÒÂÛÏ Ë ÎËÍ‚Ó) Ë TPHA ‚ ÎËÍ‚Ó, ͇ÍÚÓ Ë ÚËÔ˘ÂÌ Á‡ Á‡·ÓÎfl‚‡ÌÂÚÓ ÎËÍ‚ÓÂÌ ÒË̉ÓÏ Ì‡ ÔÎÂÓˆËÚÓÁ‡ Ë ıËÔÂÔÓÚÂËÌÓ‡ıËfl. åÂÌËÌ„Ó‚‡ÒÍÛ·ÌËflÚ çë Ò ÔÓfl‚fl‚‡ 5 ‰Ó 10 „Ó‰ËÌË ÒΉ Ô˙‚˘ÌËfl ‡ÙÂÍÚ - Ò‰ÌÓ ÓÍÓÎÓ 7 „Ó‰ËÌË. ÄÚÂËËÚ˙Ú Ì‡ Heubner Ò ı‡‡ÍÚÂËÁË‡ Ò ÎËÏÙÓˆËÚ̇ ËÌÙËÎÚ‡ˆËfl ̇ ‡‰‚ÂÌÚˈËflÚ‡ ̇ „ÓÎÂÏËÚ ÏÓÁ˙˜ÌË Ò˙‰Ó‚Â. ÄÚÂËËÚ˙Ú Ì‡ Nissl-Alzheimer  ÔÓÎËÙÂ‡ÚË‚ÂÌ ÔÓˆÂÒ Ë ‚˙‚΢‡ Ô‰ËÏÌÓ ËÌÚËχڇ ̇ χÎÍËÚ Ò˙‰Ó‚ (5). á‡Òfl„‡ÌÂÚÓ Ì‡ vasa vasorum Ô‰ËÁ‚ËÍ‚‡ ÌÂÍÓÁ‡ ̇ ÏÛÒÍÛÎÌËÚÂ Ë Â·ÒÚ˘ÌËÚ ÍÎÂÚÍË Ì‡ Ò‰ÌËfl ÒÎÓÈ Ì‡ ‡ÚÂËËÚÂ Ë ÔÓÎËÙÂ‡ˆËfl ̇ ÒÛ·ẨÓÚÂÎ̇ ÙË·ÓÁ̇ Ú˙Í‡Ì Ò ÔÓÒÚÂÔÂÌÌÓ ÒÚÂÒÌÂÌË ̇ ‡ÚÂˇÎÌËÚ ÒÚÂÌË, ÍÓÂÚÓ Ô‰‡ÁÔÓ·„‡ Í˙Ï ËÌÙ‡ÍÚÌË ÎÂÁËË. å‡ÎÍË ËÒıÂÏ˘ÌË Ó„Ìˢ‡ ÏÓ„‡Ú ‰‡ Ò ‡Á‚ËflÚ ‚ n. caudatus Ë n.

95

lenticularis. êfl‰ÍÓ ÏÓ„‡Ú ‰‡ ‚˙ÁÌËÍÌ‡Ú ‡Ì‚ËÁχÎÌË Ò˙‰Ó‚Ë ‡Á¯ËÂÌËfl. àÌÙ‡ÍÚËÚ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ·ÍÛ̇ÌË, ͇ÍÚÓ Ë ÓÚ ·‡ÒÂÈÌËÚ ̇ Ò‰̇ ÏÓÁ˙˜Ì‡ ‡ÚÂËfl (62%) Ë Ì‡ ·‡ÁË·̇ڇ ‡ÚÂËfl (12%) (ËÌÙ‡ÍÚ ‚ ÔÓÒΉ̇ڇ Ëχ ÔË ÓÔËÒ‡ÌËflÚ ÓÚ Ì‡Ò ÒÎÛ˜‡È). ç‡È-˜ÂÒÚËÚ ÒËÏÔÚÓÏË Ò‡ ıÂÏËÔ‡ÂÁË, ‡Ù‡ÁËË, ÁËÚÂÎÌË Ì‡Û¯ÂÌËfl, ‰ËÁ‡ÚËfl, è‡ÍËÌÒÓÌÓ‚ ÒË̉ÓÏ, ıÓÂÓ‡ÚÂÚÓÁ‡.(4) èË Á‡Òfl„‡Ì ̇ χÎÍËÚ ‡ÚÂËË Ì‡ ÍÓ‡Ú‡ (Ẩ‡ÚÂËËÚ Ì‡ Nissl-Alzheimer) Ò ‡Á‚Ë‚‡ ‰ÂÏÂÌÚÂÌ ÒË̉ÓÏ Ò Ì‡Û¯Â̇ Ô‡ÏÂÚ Ë ÓËÂÌÚ‡ˆËfl. 燷≇‚‡ÌË Ò‡ ‰ÂÎËË, Ò˙ÒÚÓflÌËfl ̇ χÌËfl, ̇ÎÛ‰ÌË Ë‰ÂË Ë Ô‡‡ÌÓfl. ë˙ÒÚÓflÌËÂÚÓ Ì‡ÔÓ‰Ó·fl‚‡ ÔÓ„ÂÒ˂̇ Ô‡‡ÎËÁ‡, ÌÓ ÔÒËı˘̇ڇ ÒËÏÔÚÓχÚË͇ Ì  ڇ͇ ·Ó„‡ÚÓ ËÁ‡ÁÂ̇. í‡ÁË ÙÓχ ̇ ÏÂÌËÌ„Ó‚‡ÒÍÛ·ÌËfl ÒËÙËÎËÒ Ò ̇˘‡ ÎÛÂÚ˘̇ ÔÒ‚‰ÓÔ‡‡ÎËÁ‡ (3). ÑÂÏÂ̈ËflÚ‡ ÔË ÎÛÂÚ˘̇ڇ ÔÒ‚‰ÓÔ‡‡ÎËÁ‡ Ë ÔË ÔÓ„ÂÒ˂̇ڇ Ô‡‡ÎËÁ‡, ‚˙ÔÂÍË ÒÌËÊÂ̇ڇ ˜ÂÒÚÓÚ‡ ̇ Ô‡ÂÌıËÏÌËÚ ÙÓÏË Ì‡ çë, ÓÒÚ‡‚‡ Ò‰ Ô˙‚ËÚ ‰ÂÒÂÚ Ô˘ËÌË Á‡ ËÌÚÂÎÂÍÚÛ‡ÎÂÌ ÛÔ‡‰˙Í, Ò Ó„Î‰ ̇ ÍÓÂÚÓ ÔË Ú‡ÍË‚‡ ÒÎÛ˜‡Ë Ò ÔÂÔÓ˙˜‚‡, ͇ÚÓ ÛÚËÌÌÓ ËÁÒΉ‚‡ÌÂ, ÔÓ‚Âʉ‡Ì ̇ ÒÂÓÎӄ˘̇ ‰Ë‡„ÌÓÒÚË͇ Á‡ ÛÒÚ‡ÌÓ‚fl‚‡Ì ̇ ÒËÙËÎËÒ. èË ÓÔËÒ‡ÌËfl ÓÚ Ì‡Ò ÒÎÛ˜‡È Ëχ ÎÂÍÓ Á‡·‡‚Â̇ ÏËÒÎӂ̇ ‰ÂÈÌÓÒÚ Ë ‰ËÒÍÂÚÌË Ì‡Û¯ÂÌËfl ‚ Í‡ÚÍÓÒӘ̇ڇ Ô‡ÏÂÚ, ÍÓËÚÓ ÓÚÍÎÓÌÂÌËfl ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ËÌÚÂÔÂÚË‡ÌË ‚ ÍÓÌÚÂÍÒÚ‡ ̇ „Ó ̇ÔËÒ‡ÌÓÚÓ. ÖÔËÎÂÔÚ˘ÌËÚ ÔÓfl‚Ë ÔË çë Ò‡ ӷ˘‡ÈÌË - ÓÍÓÎÓ 24% ÓÚ ‚Ò˘ÍË ·ÓÎÌË. éÔËÒ‚‡Ú Ò ÍÓÏÔÎÂÍÒÌË Ô‡ˆË‡ÎÌË ÔËÒÚ˙ÔË, ‰˙Îʇ˘Ë Ò ̇ ÚÂÏÔÓ‡Î̇ ÎÓ͇ÎËÁ‡ˆËfl ̇ ÎÛÂÚ˘ÌËfl ‚‡ÒÍÛÎËÚ, ÒÎÛ˜‡Ë Ò Ó„ÌˢÌË ‰‚Ë„‡ÚÂÎÌË ÔËÒÚ˙ÔË Ë „ÂÌÂ‡ÎËÁË‡Ì‡ ÔÂËӉ˘̇ ‡ÍÚË‚ÌÓÒÚ ÔË ÖÖÉ ËÁÒΉ‚‡Ì ËÎË ÂÔËÎÂÔÚ˘ÂÌ ÒÚ‡ÚÛÒ Í‡ÚÓ Â‰ËÌÒÚ‚Â̇ ÔÓfl‚‡ ̇ ÌÂ‡ÁÔÓÁÌ‡Ú çë (9). äÎËÌ˘ÌËÚÂ Ë ÖÖÉ ‰‡ÌÌË ÔË ÓÔËÒ‡ÌËfl ÓÚ Ì‡Ò ÒÎÛ˜‡È Ì ÌË ‰‡‰Óı‡ ÓÒÌÓ‚‡ÌË ‰‡ ÔËÂÏÂÏ Ì„ӂËÚ ÔËÔ‡‰˙˜ÌË Ò˙ÒÚÓflÌËfl ͇ÚÓ ÂÔËÎÂÔÚ˘̇ ÔÓfl‚‡. ëΉ Á‡ÔÓ˜‚‡Ì ̇ ΘÂÌËÂÚÓ Ô‡ˆËÂÌÚ˙Ú Ì  ËχΠÌÓ‚Ë ÔÓ‰Ó·ÌË Ë̈ˉÂÌÚË. Ç˙ÔÂÍË ‰Ó· ÔÓÁ̇ÚÓÚÓ ÓÚ ÔÓÔ‰‚ÚË͇ڇ Á̇˜ÂÌË ̇ ËÁ˜ÂÔ‡ÚÂÎÌÓÚÓ ‡ÁÔËÚ‚‡ÌÂ Ë ËÁÒΉ‚‡Ì ̇ ·ÓÎÌËfl, ‰Ë‡„ÌÓÁ‡Ú‡ ÔË ÚÓÁË Ô‡ˆËÂÌÚ Ì  ·Ë· ÔÓÒÚ‡‚Â̇ ‚‰̇„‡. çflÍÓÎÍÓ ÏÂÒˆ‡ ÚÓÈ Â ·ËÎ ÎÂÍÛ‚‡Ì Á‡ ÎÛÏ·Ó‡‰ËÍÛÎÂÂÌ ÒË̉ÓÏ, ÔÓ ÔÓ‚Ó‰ ·ÓÎÍË ‚ Í˙ÒÚ‡, ËÁÚ˙Ô‚‡Ì ̇ ‰‚‡Ú‡ Í‡Í‡ Ë Ú‡ÁÓ‚Ó-ÂÁÂ‚Ó‡ÌË Ì‡Û¯ÂÌËfl. èË ÔÓÒÚ˙Ô‚‡Ì ‚ ÍÎËÌË͇ڇ Ò ÛÒÚ‡ÌÓ‚fl‚‡ Í‚‡‰ËÔË‡ÏˉÂÌ ÒË̉ÓÏ Ò ÔÓ-ÒËÎÌÓ ‡Ì„‡ÊË‡Ì ̇ Í‡Í‡Ú‡, Í˙‰ÂÚÓ ÏÛÒÍÛÎÌËfl ÚÓÌÛÒ Â ÒÔ‡ÒÚ˘ÌÓ Ôӂ˯ÂÌ, ‡ ·ÓÎÌËflÚ Â Ò ‰‚ÛÒÚ‡Ì̇ ÍÓÂÏ̇ ‡ÂÙÎÂÍÒËfl Ë Ò ÍÎÓÌÛÒË Ì‡ ÒÚ˙ԇ·ڇ. Ç˙ÔÂÍË ˜Â ÌflχÏ ÔÓÚ‚˙ʉÂÌË ÓÚ åêí ̇ ÚÓ‚‡ ÌË‚Ó, ÚÂÁË ÍÎËÌ˘ÌË ÒËÏÔÚÓÏË ·Ëı‡ ÏÓ„ÎË ‰‡ Ò ӷflÒÌflÚ Ò ‚ÚÓÓ Ó„Ìˢ ‚ ÏËÂÎÓ̇. èË ÏÂÌËÌ„Ó‚‡ÒÍÛ·ÌËfl ÒËÙËÎËÒ ÏÓÊ ‰‡ ·˙‰Â Á‡ÒÂ„Ì‡Ú „˙·Ì‡˜ÌËfl ÏÓÁ˙Í Ò Í‡ÚË̇ڇ ̇ Ú‡ÌÒ‚ÂÁ‡ÎÂÌ ÏËÂÎËÚ - ̇È-˜ÂÒÚÓ Ì‡ ÚÓ‡Í‡ÎÌÓ ÌË‚Ó (Ú.Ì. ÒÔ‡ÒÚ˘̇ Ô‡‡Ô‡ÂÁ‡ ̇ Erb), Ò˙˘Ó ڇ͇ ÏÓ„‡Ú ‰‡ ·˙‰‡Ú ̇·Î˛‰‡‚‡ÌË Í‡ÚËÌË Ì‡ ÒË̉ÓÏ Ì‡ ·ÚÂ‡Î̇ ‡ÏËÓÚÓÙ˘̇ ÒÍÎÂÓÁ‡, Braun-Sequard Ë ‰.(4). åÂÌËÌ„ÓÏËÂÎËÚÌËÚ ÙÓÏË Ò‡ ÔÓ-Í˙ÒÌË Ë Ó·ËÍÌÓ‚ÂÌÓ ‚˙ÁÌËÍ‚‡Ú ÔÓ ‚ÂÏÂÚÓ Ì‡ Ô‡ÂÚ˘ÌÓ-Ú‡·ÂÚ˘ÌËfl ÒËÙËÎËÒ. ï‡‡ÍÚÂËÁË‡Ú ÒÂ Ò ÔÓ„ÂÒË‡˘‡ ‰ÓÎ̇ Ô‡‡Ô‡ÂÁ‡, Ú‡ÁÓ‚ÓÂÁÂ‚Ó‡ÌË Ì‡Û¯ÂÌËfl Ë ‚‡Ë‡˘‡ ÒÚÂÔÂÌ Ì‡ Û‚‰‡ ̇ ÒÂÚË‚ÌËÚ Ô˙Úˢ‡.(10) ëË̉ÓÏ˙Ú Ì‡ Ú‡ÌÒ‚ÂÁ‡ÎÂÌ ÏËÂÎËÚ Ë ÏÂÌËÌ„ÓÏËÂÎËÚ Úfl·‚‡ ‰‡ ·˙‰Â ‡Á„‡Ì˘‡‚‡Ì ÓÚ Ú‡·ÂÒ ‰ÓÁ‡ÎËÒ, ÍÓÈÚÓ Â Ô‡ÂÌıËÏ̇ڇ ÙÓχ ̇ ÒÔË̇Î̇ ÎÛÂÚ˘̇ ÎÂÁËfl. ëËÏÔÚÓÏËÚ ̇ Ú‡·ÂÒ‡ - ÏÛÒÍÛÎ̇ ıËÔÓÚÓÌËfl, ıËÔÓ- Ë ‡ÂÙÎÂÍÒËfl, ÒÚÂÎ͇˘Ë ·ÓÎÍË, Ô‡ÂÒÚÂÁËË, ̇Û¯ÂÌ ÒÚ‡‚ÌÓ-ÏÛÒÍÛÎÂÌ Ë ‚Ë·‡ˆËÓÌÂÌ ÛÒÂÚ, ‡Ú‡ÍÒËfl Ë ÏÂıÛÌË ‡ÁÒÚÓÈÒÚ‚‡ Ò ‰˙ÎÊ‡Ú Ì‡ Û‚‰‡ ̇ Á‡‰ÌËÚ ÍÓÂ̘ÂÚ‡ ‚ ÎÛÏ·Ó-Ò‡Í‡ÎÌËÚ ÓÚ‰ÂÎË Ë Ì‡ ‰Â„ÂÌÂ‡ˆËfl ̇ Á‡‰ÌËÚ ÒÚ˙ηˆË ̇ „˙·-


‡ÔËÎ, 2007

Å˙΄‡Ò͇ ç‚ÓÎÓ„Ëfl Bulgarian Neurology

̇˜ÌËfl ÏÓÁ˙Í. ᇷÓÎfl‚‡ÌÂÚÓ Ì‡ÒÚ˙Ô‚‡ ·‡‚ÌÓ Ò ËÌÍÛ·‡ˆËÓÌÂÌ ÔÂËÓ‰ ÓÚ 10-20 „Ó‰ËÌË, ͇ÚÓ ÚÓÁË ÒÓÍ ÏÓÊ ‰‡ ‚‡Ë‡ ÓÚ 5 ‰Ó 50 „Ó‰ËÌË, ‡ ̇ÔÓÒΉ˙Í Ò ÓÔËÒ‚‡Ú ÒÎÛ˜‡Ë Ò ·˙Á‡ ÔÓ„ÂÒËfl (̇Ô. ÔË 26 „Ӊ˯ÂÌ Ï˙Ê, 3 „Ó‰ËÌË ÒΉ ÔÓfl‚‡Ú‡ ̇ Ô˙‚˘ÌËfl ÒËÙËÎËÒ (15)). èË ÓÔËÒ‡ÌËfl ÓÚ Ì‡Ò ÒÎÛ˜‡È Ò ÛÒÚ‡ÌÓ‚fl‚‡Ú Ô‡ÂÒÚÂÁËË ‚ Í‡Í‡Ú‡, ÎÂÍÓ Ì‡Û¯ÂÌË ‚ ÒÚ‡‚ÌÓ-ÏÛÒÍÛÎÌËfl, ‚Ë·‡ˆËÓÌÌËfl Ë ‰‚ÛÏÂÌÓ-ÔÓÒÚ‡ÌÒÚ‚ÂÌËfl ÛÒÂÚ, Ú‡ÁÓ‚Ó-ÂÁÂ‚Ó‡ÌË Ì‡Û¯ÂÌËfl ÔË Ôӂ˯ÂÌ ÏÛÒÍÛÎÂÌ ÚÓÌÛÒ, ÔÓÔËÓˆÂÔÚ˂̇ ıËÔÂÂÙÎÂÍÒËfl. íÓ‚‡ Ô‡‚Ë Ï‡ÎÍÓ ‚ÂÓflÚ̇ ‚˙ÁÏÓÊÌÓÒÚÚ‡ ‰‡ Ò ͇҇ Á‡ ‡ÌÂÌ ÂÚ‡Ô Ì‡ Ú‡·ÂÒ ‰ÓÁ‡ÎËÒ, ÌÓ Ú‡Í‡‚‡ Ì Úfl·‚‡ ‰‡ Ò ÔÂÌ·„‚‡, ͇ÚÓ Ò ËÏ‡Ú Ô‰‚ˉ ̇΢ËÂÚÓ Ì‡ ÏÛ‰ÌË ÁÂÌ˘ÌË ‡͈ËË Ì‡ Ò‚ÂÚÎË̇ Ë ‰‚ÛÒÚ‡ÌÌÓ ÔӷΉÌfl‚‡Ì ̇ Ô‡ÔËÎËÚÂ. áÂÌ˘ÌËÚ ‡·ÌÓÏÌÓÒÚË, ÍÓËÚÓ Ò Ô˘ËÌfl‚‡Ú ÓÚ ‰Â„ÂÌÂ‡ˆËfl ‚ ÏÂÁÂ̈ÂÙ‡ÎÌËfl Ú„ÏÂÌÚÛÏ, Ò ÛÒÚ‡ÌÓ‚fl‚‡Ú ÔË ÔÓ˜ÚË ‚Ò˘ÍË ·ÓÎÌË Ò Ú‡·ÂÒ ‰ÓÁ‡ÎËÒ. 70-80% ÓÚ ÚÂÁË ·ÓÎÌË ËÏ‡Ú ÚËÔ˘ÂÌ ÒËÏÔÚÓÏ Ì‡ Ärgyll-Robertson (2), ı‡‡ÍÚÂËÁË‡˘ ÒÂ Ò ÏÌÓ„Ó ÚÂÒÌË, ˜ÂÒÚÓ ÌÂ‡‚ÌË ÁÂÌˈË, ÍÓËÚÓ Ì ‡„Ë‡Ú ̇ Ò‚ÂÚÎË̇, ÔË Á‡Ô‡ÁÂ̇ ‡͈Ëfl ̇ ‡ÍÓÏÓ‰‡ˆËfl (15). èË ÓÒڇ̇ÎËÚ ·ÓÎÌË Ò Ò¢‡Ú ‰Û„Ë ÓÚÍÎÓÌÂÌËfl - ‰ÌÓ ÓÚ Úflı  ‚fl·ڇ ÁÂÌ˘̇ ‡͈Ëfl ̇ Ò‚ÂÚÎË̇, ÍÓflÚÓ Ò ÓÚÍË‚‡ ‡ÌÓ ÔË Ú‡·ÂÒ‡, ‰Ó͇ÚÓ ËÒÚËÌÒÍËflÚ Argyll-Robertson, ‚ËÒˆÂ‡ÎÌËÚ ÍËÁË Ë ‡ÚÓÙËflÚ‡ ̇ ÁËÚÂÎÌËÚ ÌÂ‚Ë Ò ÔÓfl‚fl‚‡Ú ‚ Í˙ÒÌËÚ ÒÚ‡‰ËË Ì‡ ·ÓÎÂÒÚÚ‡ (15). èË ÓÔËÒ‡ÌËfl ÓÚ Ì‡Ò ÒÎÛ˜‡È, ‡ÍÓ ËÁÍβ˜ËÏ ÔӷΉÌfl‚‡ÌÂÚÓ Ì‡ Ô‡ÔËÎËÚÂ, ÎËÔÒ‚‡ Û‚‰‡ ̇ óåç. èË çë ‚ÒΉÒÚ‚Ë ̇ ·‡Á‡ÎÂÌ ÏÂÌËÌ„ËÚ Ò Á‡Òfl„‡Ú 7, 8, 6 Ë 2 óåç – Ô‰ËÏÌÓ ‚ ÚÓÁË ‰ (5). èË ÎÂÁËfl ̇ óåç, ‚ ‰ËÙÂÂ̈ˇÎÌÓ-‰Ë‡„ÌÓÒÚ˘ÌËfl ÔÎ‡Ì ‚Ë̇„Ë Úfl·‚‡ ‰‡ ‚ÎËÁ‡ Ë çë. éÔËÒ‚‡Ú Ò ÒÎÛ˜‡Ë Ò ÎÂÁËË Ì‡ óåç ·ÂÁ ‰Û„‡ Ì‚ÓÎӄ˘̇ ÒËÏÔÚÓχÚË͇, ‚Íβ˜ËÚÂÎÌÓ Ë Ò ÌÓχÎÂÌ ·ÓÈ Ì‡ ÎËÍ‚ÓÌË ÍÎÂÚÍË, Ò ÎÂ͇ ıËÔÂÔÓÚÂËÌÓ‡ıËfl Ë ÔÓÎÓÊËÚÂÎÌË ÒÂÓÎӄ˘ÌË ÚÂÒÚÓ‚Â Á‡ ÒËÙËÎËÒ (7). ç‚ÓÎÓÁËÚ ÒÏflÚ‡Ú, ˜Â ÓÔÓÁ̇‚‡ÌÂÚÓ Ì‡ çë Ëχ ÔÓ„ÓÎflÏÓ ÚÂÓÂÚ˘ÌÓ, ÓÚÍÓÎÍÓÚÓ Ô‡ÍÚ˘ÌÓ Á̇˜ÂÌË (14). èÓ‰Ó·ÂÌ ‚˙Á„Ή Ò ÔÓ‰‰˙ʇ ÓÚ ‰ÍËÚ ÒÂ˘Ë Ò Ú‡ÍË‚‡ ·ÓÎÌË. íÓ‚‡ Á‡·ÓÎfl‚‡Ì ÔÓ‰˙Îʇ‚‡ ‰‡ Ò˙˘ÂÒÚ‚Û‚‡ Ì ҇ÏÓ ‚ ÒÚ‡ÌË Ò˙Ò Ò··Ó ËÍÓÌÓÏ˘ÂÒÍÓ ‡Á‚ËÚËÚ ËÎË ÔË Á‡ÒÚ‡¯ÂÌËÚ ÍÓÌÚËÌ„ÂÌÚË. ÅÓflÚ Ì‡ „Ӊ˯ÌÓ ‰ÓÍ·‰‚‡ÌËÚ ÒÎÛ˜‡Ë ̇‡ÒÚ‚‡, ̇ÔËÏÂ ‚ ëÄô ÔÂÁ 1956 „. Ú ҇ ·ËÎË 10 000, ‡ ÔÂÁ 1990 „. - 50 000. HIV ËÌÙÂ͈ËflÚ‡ Ôӂ˯‡‚‡ ËÒ͇ ÓÚ çë. çÂÔ˙ÎÌÓÚÓ ÎÂÍÛ‚‡Ì ̇ ‡ÌÌËÚ ÙÓÏË Ì‡ ÒËÙËÎËÒ Ë ÔÓÔÛÒ͇ÌÂÚÓ Ì‡ ‰Ë‡„ÌÓÁ‡Ú‡ ÔË ‚Ò˘ÍË ÂÚ‡ÔË Ì‡ ·ÓÎÂÒÚÚ‡ Ò‡ Ù‡ÍÚÓ, ÍÓÈÚÓ ‰Ó‚Âʉ‡ ‰Ó Á‡ÒË΂‡Ì ̇ ‡ÁÔÓÒÚ‡ÌÂÌËÂÚÓ ÏÛ. éÔËÒ‚‡Ï ÚÓÁË ÒÎÛ˜‡È, Á‡ ‰‡ ÔÓ͇ÊÂÏ ‰ËÙÂÂ̈ˇÎÌÓ ‰Ë‡„ÌÓÒÚ˘ÌËÚ ÔÓ·ÎÂÏË ÔË ÚÓ‚‡ Á‡·ÓÎfl‚‡ÌÂ Ë ‰‡ ̇ÔÓÏÌËÏ, ˜Â ÒËÙËÎËÒ Úfl·‚‡ ‰‡ ‚ÎËÁ‡ ‚ Ò˙Ó·‡ÊÂÌË ͇ÚÓ Ô˘Ë̇ Á‡ ÏÂÌËÌ„ËÚË, ÏÓÁ˙˜ÌË ËÌÒÛÎÚË, ‰ÂÏÂ̈ËË, ÂÔËÎÂÔÒËË, ÎÂÁËË Ì‡ óåç Ë ·ÓÎÂÒÚË Ì‡ „˙·Ì‡˜ÌËfl ÏÓÁ˙Í. Ä‚ÚÓËÚ ËÁ͇Á‚‡Ú ·Î‡„Ó‰‡ÌÓÒÚ Ì‡ Ñ- ä. ÉÂÌÓ‚‡ Á‡ ÔÓÏÓ˘Ú‡ ÔË ËÁ‚˙¯‚‡Ì ̇ üåê ËÁÒΉ‚‡Ì ̇ Ô‡ˆËÂÌÚ‡ Ë Ô‰ÓÒÚ‡‚flÌ ̇ Ó·‡ÁËÚÂ.

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çfl„ÓÎÓ‚‡ Ñ., ëÔËÓ‚ É. ㇷÓ‡ÚÓ̇ ‰Ë‡„ÌÓÒÚË͇ ̇ ÒËÙËÎËÒ‡.Ç: ëËÙËÎËÒ. èÓ‰ ‰‡ÍˆËflÚ‡ ̇ É.ëÔËÓ‚. å‰. àÁ‰‡ÚÂÎÒÚ‚Ó ◊ÄÒÓ”, 2000, 227-252. ëÔËÓ‚ É., чÒ͇ÎÓ‚ å., çfl„ÓÎÓ‚‡ Ñ. Ç˙ıÛ Ò˙‚ÂÏÂÌ̇ڇ Ô‡ÚÓÏÓÙÓÁ‡ ̇ Ì‚ÓÒËÙËÎËÒ‡ Ò ÔËÌÓÒ ÓÚ Â‰ËÌ ÒÎÛ˜‡È. ÑÂχÚÓÎÓ„Ëfl Ë ‚ÂÌÂÓÎÓ„Ëfl. 1990, 4, 44-50. òÓÚÂÍÓ‚ è., ñ‚ÂÚ‡ÌÓ‚‡, Ö., ëÔËÓ‚ É., çfl„ÓÎÓ‚‡ Ñ., äËflÍÓ‚‡ ç., чÒ͇ÎÓ‚ å. ãËÍ‚ÓÌË ËÁÒΉ‚‡ÌËfl ÔË ·ÓÎÌË Ò ‚ÚÓ˘ÂÌ ÒËÙËÎËÒ. íÂÚË ÍÓÌ„ÂÒ Ì‡ ·˙΄‡ÒÍËÚ ‰ÂχÚÓÎÓÁË Ò ÏÂʉÛ̇Ó‰ÌÓ Û˜‡ÒÚËÂ, èÎÓ‚‰Ë‚, 1980. òÓÚÂÍÓ‚ è. ëËÙËÎËÒ Ì‡ ˆÂÌÚ‡Î̇ڇ ÌÂ‚̇ ÒËÒÚÂχ. Ç: ëËÙËÎËÒ. èÓ‰ ‰‡ÍˆËflÚ‡ ̇ É. ëÔËÓ‚. å‰. àÁ‰‡ÚÂÎÒÚ‚Ó ◊ÄÒÓ”, 2000, 156182. Bradley W, Daroff R, Fenichel G, Marsden D. Neurology in clinical practice. Spirochetal disease. Butterworth-Heinemann. 1991, 1067-1071. Goetz C. Textbook of clinical neurology. Spirochete infections. 2004, 931933. Jacob M, Salmon P, et al. Beware of neurosyphilis. J Neurol 2005, 252: 609610. Knudsen, R. Menezes MS. Neurosyphilis. 2007, e-medicine.com Phan T, Somervill E, Chen S. Intractable epilepsy as initial manifestation of neurosyphilis. Epilepsia 1999, 409:1309–1311. Rowland L, Merritt’s textbook of neurology. Spirochete infection. Williams & Wilkins, 1995, 200-208. Timmermans M, Carr J. Neurosyphilis in the moderna era. J Neurol Neurosurg Psy 2004, 75: 1727-1730. Vassileva Ö, Klissurski å, Dascalov å, Krastev E, Terziev I. The role of transcranial Doppler in assessment of patient with optic neuritis due to tuberculous optochiasmatic arachnoiditis and basal cerebral arteritis. A case report. [poster] 11th European Stroke conference, Geneva, 29 May - 1 June 2002. Cerebrovasular diseases. 13: 2002; Suppl 3, pp 77. Vassileva Ö, Klissurski å, Dascalov å. Transcranial Doppler in tuberculous meningitis: A case study. ACTA Clinica Chroatica. 2004, 43:137-142. Victor M, Ropper H, Adam’s and Victor’s principles of neurology. Neurosyphilis. Mc Graw-Hill, 620-626. Weihong L, Huazhong X. et al. Rapidly progressive tabetic neurosyphilis. Chinese Medical Journal 2003, 116 (9): 1432-1434.

ĉÂÒ Á‡ ÍÓÂÒÔÓ̉Â̈Ëfl: Ñ- å. äÎËÒÛÒÍË, ‰Ï, „·‚ÂÌ ‡ÒËÒÚÂÌÚ åÅÄã “ñ‡ˈ‡ âÓ‡Ì̇”, äÎËÌË͇ ÔÓ Ì‚ÓÎÓ„Ëfl, ÛÎ.” ÅflÎÓ ÏÓ” No 8, ëÓÙËfl 1527, ÚÂÎ: (02) 9432-160 /597 /516 e-mail: mklissurski@yahoo.com Address for correspondence M.Klissurski, MD “Queen Joanna” University Hospital, 8 Bialo more street, 1527 Sofia Tel: (02) 9432-160/ 597 /516 e-mail: mklissurski@yahoo.com

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