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Определение этиологии ишемического инсульта: пошаговый алгоритм
Определение этиологии ишемического инсульта: пошаговый алгоритм
Кулеш А.А., Демин Д.А., Мехряков С.А., Кайлева Н.А. Определение этиологии ишемического инсульта: пошаговый алгоритм. Consilium Medicum. 2025;27(11):637–645. DOI: 10.26442/20751753.2025.11.203418
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Аннотация
Определение этиологии ишемического инсульта является важнейшей задачей инсультных отделений, наравне с реперфузионной терапией и медицинской реабилитацией. Как можно более раннее установление патогенетического подтипа инсульта делает возможным назначение эффективной вторичной профилактики, что снижает риск раннего неврологического ухудшения, рецидива, а в отдаленном периоде – повторного инсульта и других сердечно-сосудистых событий. В статье диагностика причины инсульта представлена в виде последовательности из следующих 5 шагов: анализ клинических подсказок, анализ радиологических подсказок, стандартный диагностический поиск, симптом- и очаг-ориентированный поиск, исключение редких причин.
Ключевые слова: ишемический инсульт, этиология, алгоритм
Keywords: ischemic stroke, etiology, algorithm
Ключевые слова: ишемический инсульт, этиология, алгоритм
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Keywords: ischemic stroke, etiology, algorithm
Полный текст
Список литературы
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10. Babikian VL, Caplan LR. Brain embolism is a dynamic process with variable characteristics. Neurology. 2000;54(4):797-801. DOI:10.1212/wnl.54.4.797
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12. Arboix A, Alio J. Acute cardioembolic cerebral infarction: answers to clinical questions. Curr Cardiol Rev. 2012;8(1):54-67. DOI:10.2174/157340312801215791
13. Griñán K, Arboix A, Massons J, et al. Cardioembolic Stroke: Risk Factors, Clinical Features, and Early Outcome in 956 Consecutive Patients. Rev Invest Clin. 2020;73(1):023-30. DOI:10.24875/RIC.20000227
14. Kimura K, Minematsu K, Yamaguchi T, Japan Multicenter Stroke Investigators' Collaboration (J-MUSIC). Atrial fibrillation as a predictive factor for severe stroke and early death in 15,831 patients with acute ischaemic stroke. J Neurol Neurosurg Psychiatry. 2005;76(5):679-83. DOI:10.1136/jnnp.2004.048827
15. Johansen MC, Chen J, Schneider ALC, et al. Association Between Ischemic Stroke Subtype and Stroke Severity: The Atherosclerosis Risk in Communities Study. Neurology. 2023;101(9):e913-91. DOI:10.1212/WNL.0000000000207535
16. Minematsu K, Yamaguchi T, Omae T. 'Spectacular shrinking deficit': rapid recovery from a major hemispheric syndrome by migration of an embolus. Neurology. 1992;42(1):157-62. DOI:10.1212/wnl.42.1.157
17. Seners P, Baron JC. Revisiting 'progressive stroke': incidence, predictors, pathophysiology, and management of unexplained early neurological deterioration following acute ischemic stroke. J Neurol. 2018;265(1):216-25. DOI:10.1007/s00415-017-8490-3
18. Hacke W, Schwab S, Horn M, et al. 'Malignant' middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol. 1996;53(4):309-15. DOI:10.1001/archneur.1996.00550040037012
19. Barth A, Bogousslavsky J, Regli F. The clinical and topographic spectrum of cerebellar infarcts: a clinical-magnetic resonance imaging correlation study. Ann Neurol. 1993;33(5):451-6. DOI:10.1002/ana.410330507
20. Amarenco P. Cerebellar infarctions and their mechanisms. Rev Neurol (Paris). 1993;149(11):728-48. (in French).
21. Kumral E, Kisabay A, Ataç C. Lesion patterns and etiology of ischemia in superior cerebellar artery territory infarcts. Cerebrovasc Dis. 2005;19(5):283-90. DOI:10.1159/000084496
22. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008;7(10):951-64. DOI:10.1016/S1474-4422(08)70216-3
23. Knepper LE, Biller J, Tranel D, et al. Etiology of stroke in patients with Wernicke's aphasia. Stroke. 1989;20(12):1730-2. DOI:10.1161/01.str.20.12.1730
24. Hoffmann M, Chen R. The spectrum of aphasia subtypes and etiology in subacute stroke. J Stroke Cerebrovasc Dis. 2013;22(8):1385-92. DOI:10.1016/j.jstrokecerebrovasdis.2013.04.017
25. Caplan LR. "Top of the basilar" syndrome. Neurology. 1980;30(1):72-9. DOI:10.1212/wnl.30.1.72
26. Schwarz S, Egelhof T, Schwab S, Hacke W. Basilar artery embolism. Clinical syndrome and neuroradiologic patterns in patients without permanent occlusion of the basilar artery. Neurology. 1997;49(5):1346-52. DOI:10.1212/wnl.49.5.1346
27. Zhang Z, Sun X, Liu X, et al. Clinical features, etiology, and prognosis of hand knob stroke: a case series. BMC Neurol. 2022;22(1). DOI:10.1186/s12883-022-02858-0
28. Rissardo JP, Byroju VV, Mukkamalla S, Caprara ALF. A Narrative Review of Stroke of Cortical Hand Knob Area. Medicina (Kaunas). 2024;60(2):318. DOI:10.3390/medicina60020318
29. Kuschner SH, Berihun H. Robert Wartenberg Syndrome and Sign: A Review Article. TOORTHJ. 2021;15(1):13-6. DOI:10.2174/1874325002115010013
30. Brigo F, Ragnedda G, Canu P, Nardone R. Synkinetic wrist extension in distinguishing cortical hand from radial nerve palsy. Pract Neurol. 2018;18(6):520-2. DOI:10.1136/practneurol-2018-001971
31. Kang SY, Kim JS. Anterior cerebral artery infarction: stroke mechanism and clinical-imaging study in 100 patients. Neurology. 2008;70(24 Pt 2):2386-93. DOI:10.1212/01.wnl.0000314686.94007.d0
32. Kim JS, Caplan LR. Clinical Stroke Syndromes. Front Neurol Neurosci. 2016;40:72-92. DOI:10.1159/000448303
33. Virgo JD, Plant GT. Internuclear ophthalmoplegia. Pract Neurol. 2017;17(2):149-53. DOI:10.1136/practneurol-2016-001428
34. Xia C, Chen HS, Wu SW, Xu WH. Etiology of isolated pontine infarctions: a study based on high-resolution MRI and brain small vessel disease scores. BMC Neurol. 2017;17(1):216:s12883-017-0999-7. DOI:10.1186/s12883-017-0999-7
35. Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-72. DOI:10.1093/brain/awg169
36. Tao LS, Lin JJ, Zou M, et al. A comparative analysis of 375 patients with lateral and medial medullary infarction. Brain Behav. 2021;11(8):e2224:e2224. DOI:10.1002/brb3.2224
37. Vereshchagin N.V. Patologiia vertebral'no-baziliarnoi sistemy i narusheniia mozgovogo krovoobrashcheniia. Moscow: Meditsina, 1980 (in Russian).
38. Kulesh AA, Demin DA. Wallenberg–Zakharchenko syndrome in vascular neurology emergency care: A review. Consilium Medicum. 2024;26(11):711-8 (in Russian). DOI:10.26442/20751753.2024.11.203020
39. Shmidt E.V. Stenoz i tromboz sonnykh arterii i narusheniia mozgovogo krovoobrashcheniia. Moscow: Medgiz, 1963 (in Russian).
40. Callizo J, Feltgen N, Pantenburg S, et al. Cardiovascular Risk Factors in Central Retinal Artery Occlusion: Results of a Prospective and Standardized Medical Examination. Ophthalmology. 2015;122(9):1881-8. DOI:10.1016/j.ophtha.2015.05.044
41. Mac Grory B, Schrag M, Biousse V, et al. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. Stroke. 2021;52(6):e282-94. DOI:10.1161/STR.0000000000000366
42. Ting RJE, Hui M, Thoo C, et al. Light-induced Amaurosis: A Rare Manifestation of Internal Carotid Artery Stenosis. Cureus. 2019;11(10):e5817. DOI:10.7759/cureus.5817
43. Wong KS, Caplan LR, Kim JS. Stroke Mechanisms. Front Neurol Neurosci. 2016;40:58-71. DOI:10.1159/000448302
44. Huang R, Zhang X, Chen W, et al. Stroke Subtypes and Topographic Locations Associated with Neurological Deterioration in Acute Isolated Pontine Infarction. J Stroke Cerebrovasc Dis. 2016;25(1):206-13. DOI:10.1016/j.jstrokecerebrovasdis.2015.09.019
45. Romano JG, Gardener H, Smith EE, et al. Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke. Stroke. 2022;53(2):482-8. DOI:10.1161/STROKEAHA.121.034124
46. Psychogios M, Brehm A, López-Cancio E, et al. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J. 2022;7(3):III-IV. DOI:10.1177/23969873221099715
47. Caplan LR. Lacunar infarction and small Vessel disease: pathology and pathophysiology. J Stroke. 2015;17(1):2-6. DOI:10.5853/jos.2015.17.1.2
48. 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
49. Deguchi I, Takahashi S. Pathophysiology and Optimal Treatment of Intracranial Branch Atheromatous Disease. J Atheroscler Thromb. 2023;30(7):701-9. DOI:10.5551/jat.RV22003
50. Arboix A, Martí-Vilalta JL. Lacunar stroke. Expert Rev Neurother. 2009;9(2):179-96. DOI:10.1586/14737175.9.2.179
51. He L, Xu R, Wang J, et al. Capsular warning syndrome: clinical analysis and treatment. BMC Neurol. 2019;19(1):285. DOI:10.1186/s12883-019-1522-0
52. Saposnik G, Noel de Tilly L, Caplan LR. Pontine warning syndrome. Arch Neurol. 2008;65(10):1375-7. DOI:10.1001/archneur.65.10.1375
53. Stocker A, Struffert T, Engelhorn T, Huttner HB. Consecutive Lacunar Strokes Mimicking Brainstem Symptoms in a Patient With Pseudobulbar Palsy. Neurologist. 2015;20(1):16-7. DOI:10.1097/NRL.0000000000000038
54. Kulesh AA, Demin DA. Artery of Percheron stroke: A review. Consilium Medicum. 2024;26(11):734-8 (in Russian). DOI:10.26442/20751753.2024.11.203049
55. Kulesh AA, Mekhriakov SA, Demin DA, et al. Rol' ochaga infarkta mozga v opredelenii etiologii ishemicheskogo insul'ta. Nevrologiia i neirokhirurgiia. Vostochnaia Evropa. 2025;15(3):436-45 (in Russian).
56. Tanashyan MM, Kuznetsova PI, Lagoda OV, et al. Myeloproliferative diseases and ischemic stroke. Annaly klinicheskoi i eksperimental'noi nevrologii. 2014;8(2):41-5 (in Russian).
57. Arboix A, Jiménez C, Massons J, et al. Hematological disorders: a commonly unrecognized cause of acute stroke. Expert Rev Hematol. 2016;9(9):891-901. DOI:10.1080/17474086.2016.1208555
58. Demin DA, Kulesh AA, Vinogradov OI, et al. Nevrologicheskie oslozhneniia infektsionnogo endokardita: 10 pravil vedeniia patsienta. Nevrologiia, neiropsikhiatriia, psikhosomatika. 2022;14(4):4-11 (in Russian).
59. Pizova NV. Primary systemic vasculitis and damages of the central nervous system. S.S. Korsakov Journal of Neurology and Psychiatry. 2014;114(3):98‑102 (in Russian).
60. Hart RG, Diener HC, Coutts SB, et al. 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
61. Yang D, Elkind MSV. Current perspectives on the clinical management of cryptogenic stroke. Expert Rev Neurother. 2023;23(3):213-26. DOI:10.1080/14737175.2023.2192403
62. Caplan LR. Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology. 1989;39(9):1246-50. DOI:10.1212/wnl.39.9.1246
2. Кулеш А.А., Демин Д.А., Виноградов О.И. Патогенетические механизмы ишемического инсульта: от верификации до вторичной профилактики. Consilium Medicum. 2022;23(11):792-9 [Kulesh AA, Demin DA, Vinogradov OI. Pathogenetic mechanisms of ischemic stroke: from verification to secondary prevention. Consilium Medicum. 2022;23(11):792-9 (in Russian)]. DOI:10.26442/20751753.2021.11.201153
3. Демин Д.А., Кулеш А.А., Янишевский С.Н., и др. Криптогенный инсульт. Часть 3: предсердная кардиопатия и скрытая фибрилляция предсердий. Медицинский Совет. 2022;(21):8-18 [Demin DA, Kulesh AA, Yanishevskiy SN, et al. Cryptogenic stroke. Part 3: atrial cardiopathy and silent atrial fibrillation. Meditsinskiy sovet = Medical Council. 2022;(21):8-18 (in Russian)]. DOI:10.21518/2079-701x-2022-16-21-8-18
4. Кулеш А.А., Демин Д.А., Белопасова А.В., и др. Криптогенный инсульт. Часть 2: парадоксальная эмболия. Медицинский Совет. 2021;(19):16-33 [Kulesh AA, Demin DA, Belopasova AV, et al. Cryptogenic stroke. Part 2: paradoxical embolism. Meditsinskiy sovet = Medical Council. 2021;(19):16-33 (in Russian)]. DOI:10.21518/2079-701x-2021-19-16-33
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6. 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
7. 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 YA, 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
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10. Babikian VL, Caplan LR. Brain embolism is a dynamic process with variable characteristics. Neurology. 2000;54(4):797-801. DOI:10.1212/wnl.54.4.797
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30. Brigo F, Ragnedda G, Canu P, Nardone R. Synkinetic wrist extension in distinguishing cortical hand from radial nerve palsy. Pract Neurol. 2018;18(6):520-2. DOI:10.1136/practneurol-2018-001971
31. Kang SY, Kim JS. Anterior cerebral artery infarction: stroke mechanism and clinical-imaging study in 100 patients. Neurology. 2008;70(24 Pt 2):2386-93. DOI:10.1212/01.wnl.0000314686.94007.d0
32. Kim JS, Caplan LR. Clinical Stroke Syndromes. Front Neurol Neurosci. 2016;40:72-92. DOI:10.1159/000448303
33. Virgo JD, Plant GT. Internuclear ophthalmoplegia. Pract Neurol. 2017;17(2):149-53. DOI:10.1136/practneurol-2016-001428
34. Xia C, Chen HS, Wu SW, Xu WH. Etiology of isolated pontine infarctions: a study based on high-resolution MRI and brain small vessel disease scores. BMC Neurol. 2017;17(1):216:s12883-017-0999-7. DOI:10.1186/s12883-017-0999-7
35. Kim JS. Pure lateral medullary infarction: clinical-radiological correlation of 130 acute, consecutive patients. Brain. 2003;126(Pt 8):1864-72. DOI:10.1093/brain/awg169
36. Tao LS, Lin JJ, Zou M, et al. A comparative analysis of 375 patients with lateral and medial medullary infarction. Brain Behav. 2021;11(8):e2224:e2224. DOI:10.1002/brb3.2224
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41. Mac Grory B, Schrag M, Biousse V, et al. Management of Central Retinal Artery Occlusion: A Scientific Statement From the American Heart Association. Stroke. 2021;52(6):e282-94. DOI:10.1161/STR.0000000000000366
42. Ting RJE, Hui M, Thoo C, et al. Light-induced Amaurosis: A Rare Manifestation of Internal Carotid Artery Stenosis. Cureus. 2019;11(10):e5817. DOI:10.7759/cureus.5817
43. Wong KS, Caplan LR, Kim JS. Stroke Mechanisms. Front Neurol Neurosci. 2016;40:58-71. DOI:10.1159/000448302
44. Huang R, Zhang X, Chen W, et al. Stroke Subtypes and Topographic Locations Associated with Neurological Deterioration in Acute Isolated Pontine Infarction. J Stroke Cerebrovasc Dis. 2016;25(1):206-13. DOI:10.1016/j.jstrokecerebrovasdis.2015.09.019
45. Romano JG, Gardener H, Smith EE, et al. Frequency and Prognostic Significance of Clinical Fluctuations Before Hospital Arrival in Stroke. Stroke. 2022;53(2):482-8. DOI:10.1161/STROKEAHA.121.034124
46. Psychogios M, Brehm A, López-Cancio E, et al. European Stroke Organisation guidelines on treatment of patients with intracranial atherosclerotic disease. Eur Stroke J. 2022;7(3):III-IV. DOI:10.1177/23969873221099715
47. Caplan LR. Lacunar infarction and small Vessel disease: pathology and pathophysiology. J Stroke. 2015;17(1):2-6. DOI:10.5853/jos.2015.17.1.2
48. 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
49. Deguchi I, Takahashi S. Pathophysiology and Optimal Treatment of Intracranial Branch Atheromatous Disease. J Atheroscler Thromb. 2023;30(7):701-9. DOI:10.5551/jat.RV22003
50. Arboix A, Martí-Vilalta JL. Lacunar stroke. Expert Rev Neurother. 2009;9(2):179-96. DOI:10.1586/14737175.9.2.179
51. He L, Xu R, Wang J, et al. Capsular warning syndrome: clinical analysis and treatment. BMC Neurol. 2019;19(1):285. DOI:10.1186/s12883-019-1522-0
52. Saposnik G, Noel de Tilly L, Caplan LR. Pontine warning syndrome. Arch Neurol. 2008;65(10):1375-7. DOI:10.1001/archneur.65.10.1375
53. Stocker A, Struffert T, Engelhorn T, Huttner HB. Consecutive Lacunar Strokes Mimicking Brainstem Symptoms in a Patient With Pseudobulbar Palsy. Neurologist. 2015;20(1):16-7. DOI:10.1097/NRL.0000000000000038
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55. Кулеш А.А., Мехряков С.А., Демин Д.А., и др. Роль очага инфаркта мозга в определении этиологии ишемического инсульта. Неврология и нейрохирургия. Восточная Европа. 2025;15(3):436-45 [Kulesh AA, Mekhriakov SA, Demin DA, et al. Rol' ochaga infarkta mozga v opredelenii etiologii ishemicheskogo insul'ta. Nevrologiia i neirokhirurgiia. Vostochnaia Evropa. 2025;15(3):436-45 (in Russian)].
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60. Hart RG, Diener HC, Coutts SB, et al. 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
61. Yang D, Elkind MSV. Current perspectives on the clinical management of cryptogenic stroke. Expert Rev Neurother. 2023;23(3):213-26. DOI:10.1080/14737175.2023.2192403
62. Caplan LR. Intracranial branch atheromatous disease: a neglected, understudied, and underused concept. Neurology. 1989;39(9):1246-50. DOI:10.1212/wnl.39.9.1246
________________________________________________
2. Kulesh AA, Demin DA, Vinogradov OI. Pathogenetic mechanisms of ischemic stroke: from verification to secondary prevention. Consilium Medicum. 2022;23(11):792-9 (in Russian). DOI:10.26442/20751753.2021.11.201153
3. Demin DA, Kulesh AA, Yanishevskiy SN, et al. Cryptogenic stroke. Part 3: atrial cardiopathy and silent atrial fibrillation. Meditsinskiy sovet = Medical Council. 2022;(21):8-18 (in Russian). DOI:10.21518/2079-701x-2022-16-21-8-18
4. Kulesh AA, Demin DA, Belopasova AV, et al. Cryptogenic stroke. Part 2: paradoxical embolism. Meditsinskiy sovet = Medical Council. 2021;(19):16-33 (in Russian). DOI:10.21518/2079-701x-2021-19-16-33
5. Dreshina SA, Yanishevskiy SN. Rare causes of cryptogenic stroke. Russian Journal for Personalized Medicine. 2024;4(2):170-7 (in Russian). DOI:10.18705/2782-3806-2024-4-2-170-179
6. 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
7. Kulesh AA, Nurieva YA, 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
8. Ishemicheskii insul't i tranzitornaia ishemicheskaia ataka. Klinicheskie rekomendatsii. 2024. Available at: https://cr.minzdrav.gov.ru/view-cr/814_1. Accessed: 31.08.2025 (in Russian).
9. 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
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Авторы
А.А. Кулеш*1,2, Д.А. Демин1,3, С.А. Мехряков1,2, Н.А. Кайлева1,2
1ФГБОУ ВО «Пермский государственный медицинский университет им. акад. Е.А. Вагнера» Минздрава России, Пермь, Российская Федерация
2ГАУЗ Пермского края «Городская клиническая больница №4», Пермь, Российская Федерация
3ГБУЗ «Московский многопрофильный клинический центр “Коммунарка„ Департамента здравоохранения г. Москвы», Москва, Российская Федерация
*aleksey.kulesh@gmail.com
1Vagner Perm State Medical University, Perm, Russian Federation
2City Clinical Hospital №4, Perm, Russian Federation
3Moscow Multidisciplinary Clinical Center "Kommunarka", Moscow, Russian Federation
*aleksey.kulesh@gmail.com
1ФГБОУ ВО «Пермский государственный медицинский университет им. акад. Е.А. Вагнера» Минздрава России, Пермь, Российская Федерация
2ГАУЗ Пермского края «Городская клиническая больница №4», Пермь, Российская Федерация
3ГБУЗ «Московский многопрофильный клинический центр “Коммунарка„ Департамента здравоохранения г. Москвы», Москва, Российская Федерация
*aleksey.kulesh@gmail.com
________________________________________________
1Vagner Perm State Medical University, Perm, Russian Federation
2City Clinical Hospital №4, Perm, Russian Federation
3Moscow Multidisciplinary Clinical Center "Kommunarka", Moscow, Russian Federation
*aleksey.kulesh@gmail.com
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