Патогенетические механизмы ишемического инсульта: от верификации до вторичной профилактики
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
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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
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
________________________________________________
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
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.
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.
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1. Tarulli A. Uncommon causes of stroke and stroke mimics. In: The Stroke Book. Ed. M. Torbey, M. Selim. Cambridge: Cambridge UP, 2013; p. 74-92. DOI:10.1017/CBO9781139344296.008
2. Kulesh AA, Drobakha VE, Shestakov VV. Cryptogenic stroke. Neurology, Neuropsychiatry, Psychosomatics. 2019;11(4):14-21 (in Russian) DOI:10.14412/2074-2711-2019-4-14-21
3. Radu RA, Terecoasă EO, Băjenaru OA, Tiu C. Etiologic classification of ischemic stroke: Where do we stand? Clin Neurol Neurosurg. 2017;159:93-106. DOI:10.1016/j.clineuro.2017.05.019
4. Ay H, Benner T, Arsava EM, et al. A computerized algorithm for etiologic classification of ischemic stroke: The Causative Classification of Stroke System. Stroke. 2007;38(11):2979-84. DOI:10.1161/STROKEAHA.107.490896
5. Hart RG, Diener HC, Coutts SB, et al.; Cryptogenic Stroke/ESUS International Working Group. Embolic strokes of undetermined source: the case for a new clinical construct. Lancet Neurol. 2014;13(4):429-38. DOI:10.1016/S1474-4422(13)70310-7
6. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021;52(7):e364-e467. DOI:10.1161/STR.0000000000000375
7. Kamel H, Healey JS. Cardioembolic Stroke. Circ Res. 2017;120(3):514-26.
DOI:10.1161/CIRCRESAHA.116.308407
8. Sacchetti DC, Furie KL, Yaghi S. Cardioembolic Stroke: Mechanisms and Therapeutics. Semin Neurol. 2017;37(3):326-38. DOI:10.1055/s-0037-1603465
9. Kang J, Hong JH, Jang MU, et al. Cardioembolism and Involvement of the Insular Cortex in Patients with Ischemic Stroke. PLoS One. 2015;10(10):e0139540. DOI:10.1371/journal.pone.0139540
10. Friberg L, Hammar N, Rosenqvist M. Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial Fibrillation. Eur Heart J. 2010;31(8):967-75.
DOI:10.1093/eurheartj/ehn599
11. Haeusler KG, Laufs U, Endres M. Chronic heart failure and ischemic stroke. Stroke.
2011;42(10):2977-82. DOI:10.1161/STROKEAHA.111.628479
12. Solheim S, Seljeflot I, Lunde K, et al. Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy. Am J Cardiol. 2010;106(9):1197-200. DOI:10.1016/j.amjcard.2010.06.043
13. Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: a meta-analysis. J Am Coll Cardiol. 1993;22(4):1004-9. DOI:10.1016/0735-1097(93)90409-t
14. Leow AS, Sia CH, Tan BY, et al. Characterisation of acute ischemic stroke in patients with left ventricular thrombi after myocardial infarction. J Thromb Thrombolysis. 2019;48(1):158-66. DOI:10.1007/s11239-019-01829-6
15. García-Cabrera E, Fernández-Hidalgo N, Almirante B, et al.; Group for the Study of Cardiovascular Infections of the Andalusian Society of Infectious Diseases; Spanish Network for Research in Infectious Diseases. Neurological complications of infective endocarditis: risk factors, outcome, and impact of cardiac surgery: a multicenter observational study. Circulation. 2013;127(23):2272-84.
DOI:10.1161/CIRCULATIONAHA.112.000813
16. Dalager-Pedersen M, Søgaard M, Schønheyder HC, et al. Risk for myocardial infarction and stroke after community-acquired bacteremia: A 20-year population-based cohort study. Circulation. 2014;129(13):1387-96. DOI:10.1161/CIRCULATIONAHA.113.006699
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
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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
________________________________________________
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