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Патогенетические механизмы ишемического инсульта: от верификации до вторичной профилактики
Кулеш А.А., Демин Д.А., Виноградов О.И. Патогенетические механизмы ишемического инсульта: от верификации до вторичной профилактики. Consilium Medicum. 2021;23(11):792–799.
DOI: 10.26442/20751753.2021.11.201153
DOI: 10.26442/20751753.2021.11.201153
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Kulesh AA, Demin DA, Vinogradov OI. Pathogenetic mechanisms of ischemic stroke: from verification to secondary prevention. Consilium Medicum. 2021;23(11):792–799. DOI: 10.26442/20751753.2021.11.201153
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Аннотация
Ишемический инсульт представляет собой чрезвычайно гетерогенное заболевание: существует более 200 причин мозговой катастрофы. Раннее установление патогенетического механизма (подтипа) ишемического инсульта позволяет спланировать индивидуальную стратегию вторичной профилактики, которая включает широкий спектр медикаментозных и хирургических методов. В статье представлена характеристика кардиоэмболического (на фоне фибрилляции и трепетания предсердий, протезированных клапанов, хронической сердечной недостаточности, тромба в левом желудочке, инфекционного эндокардита, открытого овального окна и др.), атеротромботического (вследствие экстра- и интракраниального атеросклероза), лакунарного и криптогенного инсульта, а также более редких причин заболевания, в частности диссекции артерий шеи и головного мозга. Освещены и обобщены в виде алгоритма вопросы вторичной профилактики инсульта в зависимости от патогенетического подтипа. Статья иллюстрирована клиническими примерами.
Ключевые слова: ишемический инсульт, механизмы, подтипы, диагностика, вторичная профилактика
Ключевые слова: ишемический инсульт, механизмы, подтипы, диагностика, вторичная профилактика
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Ischemic stroke is an extremely heterogeneous disease: there are more than 200 causes of cerebral catastrophe. Early identification of the pathogenetic mechanism (subtype) of ischemic stroke allows planning an individual secondary prevention strategy, which includes a wide range of pharmaceutical and surgical methods. The article presents the characteristics of cardioembolic (associated with atrial fibrillation and flutter, prosthetic valves, chronic heart failure, left ventricle thrombus, infective endocarditis, open foramen ovale, etc.), atherothrombotic (due to extra- and intracranial atherosclerosis), lacunar and cryptogenic stroke, as well as less common causes of the disease, in particular cervical or cerebral artery dissection. Issues of secondary prevention of stroke according to the pathogenetic subtype are described and summarized as an algorithm. The article is illustrated with clinical examples.
Keywords: ischemic stroke, mechanisms, subtypes, diagnostics, secondary prevention
Полный текст
Список литературы
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18. Diener HC, Sacco RL, Easton JD, et al.; RE-SPECT ESUS Steering Committee and Investigators. Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. N Engl J Med. 2019;380(20):1906-17. DOI:10.1056/NEJMoa1813959
19. Hart RG, Sharma M, Mundl H, et al.; NAVIGATE ESUS Investigators. Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med. 2018;378(23):2191-201. DOI:10.1056/NEJMoa1802686
20. Кулеш А.А., Нуриева Ю.А., Сыромятникова Л.И. Причины ишемического инсульта у пациентов моложе 45 лет: анализ данных регионального сосудистого центра. Неврология, нейропсихиатрия, психосоматика. 2021;13(1):24-30 [Kulesh AA, Nurieva YuA, Syromyatnikova LI. Causes of ischemic stroke in patients younger than 45 years: analysis of data from the regional vascular center. Neurology, Neuropsychiatry, Psychosomatics. 2021;13(1):24-30 (in Russian)]. DOI:10.14412/2074-2711-2021-1-24-30
21. Кулеш А.А., Шестаков В.В. Открытое овальное окно и эмболический криптогенный инсульт. Неврология, нейропсихиатрия, психосоматика. 2019;11(2):4-11 [Kulesh AA, Shestakov VV. Patent foramen ovale and embolic cryptogenic stroke. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2019;11(2):4-11 (in Russian)]. DOI:10.14412/2074-2711-2019-2-4-11
22. Bannan A, Shen R, Silvestry FE, Herrmann HC. Characteristics of adult patients with atrial septal defects presenting with paradoxical embolism. Catheter Cardiovasc Interv. 2009;74(7):1066-9. DOI:10.1002/ccd.22170
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[Belopasova AV, Dobrynina LA, Kalashnikova LA, et al. Pulmonary arteriovenous shunt – a rare cause of recurrent stroke due to paradoxical embolism. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2020;120(9):107-13 (in Russian)]. DOI:10.17116/jnevro2020120091107
24. Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331(22):1474-9. DOI:10.1056/NEJM199412013312202
25. Cui X, Li Y, Liu J, et al. Aortic arch atheroma and the risk of stroke: a meta-analysis. J Evid Based Med. 2014;7(3):185-91. DOI:10.1111/jebm.12113
26. Vizzardi E, Gelsomino S, D’Aloia A, Lorusso R. Aortic atheromas and stroke: review of literature. J Investig Med. 2013;61(6):956-66. DOI:10.2310/JIM.0b013e31829cbe04
27. Кулеш А.А., Демин Д.А., Виноградов О.И. Криптогенный инсульт. Часть 1: аорто-артериальная эмболия. Медицинский совет. 2021;(4):78-87 [Kulesh AA, Demin DA, Vinogradov OI. Cryptogenic stroke. Part 1: Aorto-arterial embolism. Meditsinskiy sovet = Medical Council. 2021;(4):78-87 (in Russian)]. DOI:10.21518/2079-701X-2021-4-78-87
28. Goyal M, Singh N, Marko M, et al. Embolic Stroke of Undetermined Source and Symptomatic Nonstenotic Carotid Disease. Stroke. 2020;51(4):1321-5. DOI:10.1161/STROKEAHA.119.028853
29. Barrett KM, Brott TG. Stroke Caused by Extracranial Disease. Circ Res. 2017;120(3):496-501. DOI:10.1161/CIRCRESAHA.117.310138
30. Banerjee C, Chimowitz MI. Stroke Caused by Atherosclerosis of the Major Intracranial Arteries. Circ Res. 2017;120(3):502-13. DOI:10.1161/CIRCRESAHA.116.308441
31. Kim JS, Caplan LR. Clinical Stroke Syndromes. Front Neurol Neurosci. 2016;40:72-92. DOI:10.1159/000448303
32. Gorelick PB, Wong KS, Bae HJ, Pandey DK. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke. 2008;39(8):2396-9. DOI:10.1161/STROKEAHA.107.505776
33. Hurford R, Wolters FJ, Li L, et al.; Oxford Vascular Study Phenotyped Cohort. Prevalence, predictors, and prognosis of symptomatic intracranial stenosis in patients with transient ischaemic attack or minor stroke: a population-based cohort study. Lancet Neurol. 2020;19(5):413-21. DOI:10.1016/S1474-4422(20)30079-X
34. Qureshi AI, Caplan LR. Intracranial atherosclerosis. Lancet. 2014;383(9921):984-98.
DOI:10.1016/S0140-6736(13)61088-0
35. Hoshino T, Sissani L, Labreuche J, et al.; AMISTAD Investigators. Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease. JAMA Neurol. 2018;75(2):203-11. DOI:10.1001/jamaneurol.2017.3960
36. Krasteva MP, Lau KK, Mordasini P, et al. Intracranial Atherosclerotic Stenoses: Pathophysiology, Epidemiology, Risk Factors and Current Therapy Options. Adv Ther. 2020;37(5):1829-65. DOI:10.1007/s12325-020-01291-4
37. Regenhardt RW, Das AS, Lo EH, Caplan LR. Advances in Understanding the Pathophysiology of Lacunar Stroke: A Review. JAMA Neurol. 2018;75(10):1273-81. DOI:10.1001/jamaneurol.2018.1073
38. Wardlaw JM, Smith EE, Biessels GJ, et al. Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol. 2013;12:822-38. DOI:10.1016/S1474-4422(13)70124-8
39. Кулеш А.А., Дробаха В.Е., Шестаков В.В. Церебральная болезнь мелких сосудов: классификация, клинические проявления, диагностика и особенности лечения. Неврология, нейропсихиатрия, психосоматика. 2019;11(3S):4-17 [Kulesh AA, Drobakha VE, Shestakov VV. Cerebral small vessel disease: classification, clinical manifestations, diagnosis, and features of treatment. Neurology, Neuropsychiatry, Psychosomatics. 2019;11(3S):4-17 (in Russian)].
DOI:10.14412/2074-2711-2019-3S-4-17
40. Regenhardt RW, Das AS, Ohtomo R, et al. Pathophysiology of Lacunar Stroke: History’s Mysteries and Modern Interpretations. J Stroke Cerebrovasc Dis. 2019;28(8):2079-97. DOI:10.1016/j.jstrokecerebrovasdis.2019.05.006
41. Giacomozzi S, Caso V, Agnelli G, et al. Lacunar stroke syndromes as predictors of lacunar and non-lacunar infarcts on neuroimaging: a hospital-based study. Intern Emerg Med. 2020;15(3):429-36. DOI:10.1007/s11739-019-02193-2
42. Kamo H, Miyamoto N, Otani H, et al. The Importance of Combined Antithrombotic Treatment for Capsular Warning Syndrome. J Stroke Cerebrovasc Dis. 2018;27(11):3095-9. DOI:10.1016/j.jstrokecerebrovasdis.2018.06.038
43. Кулеш А.А., Емелин А.Ю., Боголепова А.Н., и др. Клинические проявления и вопросы диагностики хронического цереброваскулярного заболевания (хронической ишемии головного мозга) на ранней (додементной) стадии. Неврология, нейропсихиатрия, психосоматика. 2021;13(1):4-12 [Kulesh AA, Emelin AYu, Bogolepova AN, et al. Clinical manifestations and issues of diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia) at an early (pre-dementia) stage. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(1):4-12 (in Russian)]. DOI:10.14412/2074-2711-2021-1-4-12
44. Hart RG, Catanese L, Perera KS, et al. Embolic Stroke of Undetermined Source: A Systematic Review and Clinical Update. Stroke. 2017;48(4):867-72. DOI:10.1161/STROKEAHA.116.016414
45. Cucchiara B, Kasner S. Treatment of “Other” Stroke Etiologies. In: Stroke. Pathophysiology, Diagnosis, and Management Book. Seventh Edition. Elsevier, 2022; p. 852-868.e9. DOI:10.1016/B978-0-323-69424-7.00058-2
46. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8:668-78. DOI:10.1016/S1474-4422(09)70084-5
47. Debette S, Compter A, Labeyrie MA, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol. 2015;14:640-54.
DOI:10.1016/S1474-4422(15)00009-5
48. Калашникова Л.А., Добрынина Л.А., Чечеткин А.О., и др. Нарушения мозгового кровообращения при диссекции внутренней сонной и позвоночной артерий. Алгоритм диагностики. Нервные болезни. 2016;2:10-7 [Kalashnikova LA, Dobrynina LA, Chechetkin AO, et al. Narushenija mozgovogo krovoobrashhenija pri dissekcii vnutrennej sonnoj i pozvonochnoj arterij. Algoritm diagnostiki. Nervnye bolezni. 2016;2:10-7 (in Russian)].
49. Amarenco P, Bogousslavsky J, Caplan LR, et al. The ASCOD phenotyping of ischemic stroke (Updated ASCO Phenotyping). Cerebrovasc Dis. 2013;36(1):1-5. DOI:10.1159/000352050
50. Saver JL. Clinical Practice. Cryptogenic Stroke. N Engl J Med. 2016;374(21):2065-74. DOI:10.1056/NEJMcp1503946
51. Baumgartner H, Falk V, Bax JJ, et al.; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739-91. DOI:10.1093/eurheartj/ehx391
52. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72-e227. DOI:10.1161/CIR.0000000000000923
________________________________________________
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17. Cahill TJ, Baddour LM, Habib G, et al. Challenges in Infective Endocarditis. J Am Coll Cardiol. 2017;69(3):325-44. DOI:10.1016/j.jacc.2016.10.066
18. Diener HC, Sacco RL, Easton JD, et al.; RE-SPECT ESUS Steering Committee and Investigators. Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source. N Engl J Med. 2019;380(20):1906-17. DOI:10.1056/NEJMoa1813959
19. Hart RG, Sharma M, Mundl H, et al.; NAVIGATE ESUS Investigators. Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source. N Engl J Med. 2018;378(23):2191-201. DOI:10.1056/NEJMoa1802686
20. Kulesh AA, Nurieva YuA, Syromyatnikova LI. Causes of ischemic stroke in patients younger than 45 years: analysis of data from the regional vascular center. Neurology, Neuropsychiatry, Psychosomatics. 2021;13(1):24-30 (in Russian) DOI:10.14412/2074-2711-2021-1-24-30
21. Kulesh AA, Shestakov VV. Patent foramen ovale and embolic cryptogenic stroke. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2019;11(2):4-11 (in Russian) DOI:10.14412/2074-2711-2019-2-4-11
22. Bannan A, Shen R, Silvestry FE, Herrmann HC. Characteristics of adult patients with atrial septal defects presenting with paradoxical embolism. Catheter Cardiovasc Interv. 2009;74(7):1066-9. DOI:10.1002/ccd.22170
23. Belopasova AV, Dobrynina LA, Kalashnikova LA, et al. Pulmonary arteriovenous shunt – a rare cause of recurrent stroke due to paradoxical embolism. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2020;120(9):107-13 (in Russian)
DOI:10.17116/jnevro2020120091107
24. Amarenco P, Cohen A, Tzourio C, et al. Atherosclerotic disease of the aortic arch and the risk of ischemic stroke. N Engl J Med. 1994;331(22):1474-9. DOI:10.1056/NEJM199412013312202
25. Cui X, Li Y, Liu J, et al. Aortic arch atheroma and the risk of stroke: a meta-analysis. J Evid Based Med. 2014;7(3):185-91. DOI:10.1111/jebm.12113
26. Vizzardi E, Gelsomino S, D’Aloia A, Lorusso R. Aortic atheromas and stroke: review of literature. J Investig Med. 2013;61(6):956-66. DOI:10.2310/JIM.0b013e31829cbe04
27. Kulesh AA, Demin DA, Vinogradov OI. Cryptogenic stroke. Part 1: Aorto-arterial embolism. Meditsinskiy sovet = Medical Council. 2021;(4):78-87 (in Russian)
DOI:10.21518/2079-701X-2021-4-78-87
28. Goyal M, Singh N, Marko M, et al. Embolic Stroke of Undetermined Source and Symptomatic Nonstenotic Carotid Disease. Stroke. 2020;51(4):1321-5. DOI:10.1161/STROKEAHA.119.028853
29. Barrett KM, Brott TG. Stroke Caused by Extracranial Disease. Circ Res. 2017;120(3):496-501. DOI:10.1161/CIRCRESAHA.117.310138
30. Banerjee C, Chimowitz MI. Stroke Caused by Atherosclerosis of the Major Intracranial Arteries. Circ Res. 2017;120(3):502-13. DOI:10.1161/CIRCRESAHA.116.308441
31. Kim JS, Caplan LR. Clinical Stroke Syndromes. Front Neurol Neurosci. 2016;40:72-92. DOI:10.1159/000448303
32. Gorelick PB, Wong KS, Bae HJ, Pandey DK. Large artery intracranial occlusive disease: a large worldwide burden but a relatively neglected frontier. Stroke. 2008;39(8):2396-9. DOI:10.1161/STROKEAHA.107.505776
33. Hurford R, Wolters FJ, Li L, et al.; Oxford Vascular Study Phenotyped Cohort. Prevalence, predictors, and prognosis of symptomatic intracranial stenosis in patients with transient ischaemic attack or minor stroke: a population-based cohort study. Lancet Neurol. 2020;19(5):413-21. DOI:10.1016/S1474-4422(20)30079-X
34. Qureshi AI, Caplan LR. Intracranial atherosclerosis. Lancet. 2014;383(9921):984-98.
DOI:10.1016/S0140-6736(13)61088-0
35. Hoshino T, Sissani L, Labreuche J, et al.; AMISTAD Investigators. Prevalence of Systemic Atherosclerosis Burdens and Overlapping Stroke Etiologies and Their Associations With Long-term Vascular Prognosis in Stroke With Intracranial Atherosclerotic Disease. JAMA Neurol. 2018;75(2):203-11. DOI:10.1001/jamaneurol.2017.3960
36. Krasteva MP, Lau KK, Mordasini P, et al. Intracranial Atherosclerotic Stenoses: Pathophysiology, Epidemiology, Risk Factors and Current Therapy Options. Adv Ther. 2020;37(5):1829-65. DOI:10.1007/s12325-020-01291-4
37. Regenhardt RW, Das AS, Lo EH, Caplan LR. Advances in Understanding the Pathophysiology of Lacunar Stroke: A Review. JAMA Neurol. 2018;75(10):1273-81. DOI:10.1001/jamaneurol.2018.1073
38. Wardlaw JM, Smith EE, Biessels GJ, et al. Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration. Lancet Neurol. 2013;12:822-38. DOI:10.1016/S1474-4422(13)70124-8
39. Kulesh AA, Drobakha VE, Shestakov VV. Cerebral small vessel disease: classification, clinical manifestations, diagnosis, and features of treatment. Neurology, Neuropsychiatry, Psychosomatics. 2019;11(3S):4-17 (in Russian)
DOI:10.14412/2074-2711-2019-3S-4-17
40. Regenhardt RW, Das AS, Ohtomo R, et al. Pathophysiology of Lacunar Stroke: History’s Mysteries and Modern Interpretations. J Stroke Cerebrovasc Dis. 2019;28(8):2079-97. DOI:10.1016/j.jstrokecerebrovasdis.2019.05.006
41. Giacomozzi S, Caso V, Agnelli G, et al. Lacunar stroke syndromes as predictors of lacunar and non-lacunar infarcts on neuroimaging: a hospital-based study. Intern Emerg Med. 2020;15(3):429-36. DOI:10.1007/s11739-019-02193-2
42. Kamo H, Miyamoto N, Otani H, et al. The Importance of Combined Antithrombotic Treatment for Capsular Warning Syndrome. J Stroke Cerebrovasc Dis. 2018;27(11):3095-9. DOI:10.1016/j.jstrokecerebrovasdis.2018.06.038
43. Kulesh AA, Emelin AYu, Bogolepova AN, et al. Clinical manifestations and issues of diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia) at an early (pre-dementia) stage. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(1):4-12 (in Russian)
DOI:10.14412/2074-2711-2021-1-4-12
44. Hart RG, Catanese L, Perera KS, et al. Embolic Stroke of Undetermined Source: A Systematic Review and Clinical Update. Stroke. 2017;48(4):867-72. DOI:10.1161/STROKEAHA.116.016414
45. Cucchiara B, Kasner S. Treatment of “Other” Stroke Etiologies. In: Stroke. Pathophysiology, Diagnosis, and Management Book. Seventh Edition. Elsevier, 2022; p. 852-868.e9. DOI:10.1016/B978-0-323-69424-7.00058-2
46. Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009;8:668-78. DOI:10.1016/S1474-4422(09)70084-5
47. Debette S, Compter A, Labeyrie MA, et al. Epidemiology, pathophysiology, diagnosis, and management of intracranial artery dissection. Lancet Neurol. 2015;14:640-54.
DOI:10.1016/S1474-4422(15)00009-5
48. Kalashnikova LA, Dobrynina LA, Chechetkin AO, et al. Narushenija mozgovogo krovoobrashhenija pri dissekcii vnutrennej sonnoj i pozvonochnoj arterij. Algoritm diagnostiki. Nervnye bolezni. 2016;2:10-7 (in Russian)
49. Amarenco P, Bogousslavsky J, Caplan LR, et al. The ASCOD phenotyping of ischemic stroke (Updated ASCO Phenotyping). Cerebrovasc Dis. 2013;36(1):1-5. DOI:10.1159/000352050
50. Saver JL. Clinical Practice. Cryptogenic Stroke. N Engl J Med. 2016;374(21):2065-74. DOI:10.1056/NEJMcp1503946
51. Baumgartner H, Falk V, Bax JJ, et al.; ESC Scientific Document Group. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739-91. DOI:10.1093/eurheartj/ehx391
52. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143(5):e72-e227. DOI:10.1161/CIR.0000000000000923
Авторы
А.А. Кулеш*1, Д.А. Демин2, О.И. Виноградов3
1 ФГБОУ ВО «Пермский государственный медицинский университет им. акад. Е.А. Вагнера» Минздрава России, Пермь, Россия;
2 ФГБУ «Федеральный центр сердечно-сосудистой хирургии» Минздрава России, Астрахань, Россия;
3 ФГБУ «Национальный медико-хирургический центр им. Н.И. Пирогова» Минздрава России, Москва, Россия
*aleksey.kulesh@gmail.com
1 ФГБОУ ВО «Пермский государственный медицинский университет им. акад. Е.А. Вагнера» Минздрава России, Пермь, Россия;
2 ФГБУ «Федеральный центр сердечно-сосудистой хирургии» Минздрава России, Астрахань, Россия;
3 ФГБУ «Национальный медико-хирургический центр им. Н.И. Пирогова» Минздрава России, Москва, Россия
*aleksey.kulesh@gmail.com
________________________________________________
Aleksey A. Kulesh*1, Dmitrii A. Demin2, Oleg I. Vinogradov3
1 Wagner Perm State Medical University, Perm, Russia;
2 Federal Center for Cardiovascular Surgery, Astrakhan, Russia;
3 Pirogov National Medical and Surgical Center, Moscow, Russia
*aleksey.kulesh@gmail.com
Цель портала OmniDoctor – предоставление профессиональной информации врачам, провизорам и фармацевтам.