medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2020-11-82-91medsovet-5756Research ArticleНЕВРОЛОГИЯNEUROLOGYСовременная концепция нейропротективной терапии в остром периоде ишемического инсультаThe modern concept of neuroprotective therapy in the acute period of ischemic strokehttps://orcid.org/0000-0001-6061-8118КулешА. А.KuleshA. A.

Кулеш Алексей Александрович, д.м.н., профессор кафедры неврологии и медицинской генетики; заведующий неврологическим отделением для больных с острыми нарушениями мозгового кровообращения Регионального сосудистого центра

614000, Пермь, ул. Петропавловская, д. 26

614107, Пермь, ул. Ким, д. 2

Aleksey A. Kulesh, Dr. of Sci. (Med.), professor of the Department of Neurology and Medical Genetics; Head of the Neurological Department for Patients with Acute Cerebral Circulation Disorders of the Regional Vascular Center

26, Petropavlovskaya St., Perm, 614000

2, Kim St., Perm, 614107

aleksey.kulesh@gmail.comПермский государственный медицинский университет им. академика Е.А. Вагнера; Городская клиническая больница №4РоссияE.A. Vagner Perm State Medical University; City Clinical Hospital No. 4Russian Federation2020060820200118291Copyright © Кулеш А.А., 20202020Кулеш А.А.Kulesh A.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.med-sovet.pro/jour/article/view/5756

В последние годы достигнуты значительные успехи в лечении острого ишемического инсульта. С учетом тенденции к увеличению доли пациентов, которым проводится внутривенный тромболизис и/или механическая тромбоэкстракция, оправдан вопрос: осталось ли место для нейропротективной терапии (НТ) в эпоху активного внедрения реперфузионного лечения? В обзоре рассмотрены основные механизмы поражения головного мозга при ишемии/ реперфузии и ведущие нейропротективные стратегии, изученные в клинических исследованиях. Представлены нейропротективные подходы, направленные на подавление эксайтотоксичности, оксидантного и нитрозативного стресса. Обсуждена клиническая эффективность сульфата магния, мочевой кислоты и эдаравона. Охарактеризованы немедикаментозные методы нейропротекции, в числе которых дистанционное ишемическое кондиционирование, терапевтическая гипотермия и нейростимуляция. Обсуждена НТ в ситуации невозможности обеспечения церебральной реперфузии. Проанализированы результаты рандомизированных клинических исследований и метаанализов, посвященных цитиколину. Приведен клинический случай, иллюстрирующий ведение пациента, у которого в силу течения заболевания проведение реперфузионной терапии было неосуществимо. В эпоху активного развития реперфузионных методов лечения ишемического инсульта изменилось целеполагание НТ: она призвана расширить возможности применения и повысить эффективность внутривенного тромболизиса и/или механической тромбоэкстракции, а также нивелировать их негативные реперфузионные эффекты. Основными мишенями для НТ остаются эксайтотоксичность, оксидантный и нитрозативный стресс. С другой стороны, реальная клиническая ситуация, связанная с низкой частотой применения реперфузионных технологий в нашей стране, диктует необходимость применения нейропротекторов, эффективных у данной категории пациентов. В этом отношении назначение цитиколина увеличивает шансы на восстановление функциональной независимости. Наиболее эффективно применение препарата начиная с первого дня заболевания в дозе 2000 мг/сут внутривенно в течение не менее 4–6 нед. с дальнейшим длительным пероральным приемом в дозе 1000 мг/сут.

In recent years, significant successes have been achieved in the treatment of acute ischemic stroke. Given the trend towards an increase in the proportion of patients undergoing intravenous thrombolysis and / or mechanical thrombectomy, the question justifies: is there place for neuroprotective therapy (NT) in the era of active introduction of reperfusion treatment? The review discusses the main mechanisms of brain damage in ischemia / reperfusion and the leading neuroprotective strategies studied in clinical trials. Neuroprotective approaches to suppress excitotoxicity, oxidative and nitrosative stress are presented. The clinical efficacy of magnesium sulfate, uric acid, and edaravone is discussed. Non-pharmacological methods of neuroprotection have been characterized, including remote ischemic conditioning, therapeutic hypothermia and neurostimulation. NT in a situation of impossibility of cerebral reperfusion is discussed. The results of randomized clinical trials and meta-analyzes on citicoline (ceraxon) are analyzed. A clinical case is presented illustrating the management of a patient for whom reperfusion therapy was not feasible due to the course of the disease. In the era of the active development of reperfusion methods for the treatment of ischemic stroke, the goal-setting of NT has changed: it is intended to expand the possibilities of application and increase the effectiveness of intravenous thrombolysis and/or mechanical thrombectome, as well as neutralize their negative reperfusion effects. The main targets for NT remain excitotoxicity, oxidative and nitrosative stress. On the other hand, the real clinical situation associated with the low frequency of reperfusion technology in our country necessitates the use of neuroprotectors effective in this category of patients. In this regard, the administration of ceraxon increases the chances of achieving functional independence. The most effective use of the drug from the first day of the disease at a dose of 2000 mg per day intravenously for at least 4-6 weeks with further long-term oral administration at a dose of 1000 mg per day.

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The authors declare that there are no conflicts of interest present.