medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2021-4-78-87medsovet-6093Research ArticleНЕВРОЛОГИЯNEUROLOGYКриптогенный инсульт. Часть 1: аорто-артериальная эмболияCryptogenic stroke. Part 1: Aorto-arterial embolismhttps://orcid.org/0000-0001-6061-8118КулешА. А.KuleshA. A.

Кулеш Алексей Александрович, доктор медицинских наук, доцент, профессор кафедры неврологии и медицинской генетики

614000, Пермь, ул. Петропавловская, д. 26

Aleksey A. Kulesh, Dr. Sci. (Med.), Associate Professor, Professor of the Department of Neurology and Medical Genetics

26, Petropavlovskaya St., Perm, 614990

aleksey.kulesh@gmail.comhttps://orcid.org/0000-0003-2670-4172ДеминД. А.DeminD. A.

Демин Дмитрий Алексеевич, врач-невролог

414011, Астрахань, ул. Покровская Роща, д. 4

Dmitry A. Demin, Neurologist

4, Pokrovskaya Roscha St, Astrakhan, 414011

demin2404@mail.ruhttps://orcid.org/0000-0002-3847-9366ВиноградовО. И.VinogradovO. I.

Виноградов Олег Иванович, доктор медицинских наук, профессор, заведующий кафедрой неврологии с курсом нейрохирургии

105203, Москва, ул. Нижняя Первомайская, д. 70

Oleg I. Vinogradov, Dr. Sci. (Med.), Professor, Head of the Department of Neurology with a Course in Neurosurger

70, Nizhnyaya Pervomayskaya St., Moscow, 105203

olvinog1975@gmail.comПермский государственный медицинский университет имени академика Е.А. ВагнераРоссияVagner Perm State Medical UniversityRussian FederationФедеральный центр сердечно-сосудистой хирургии (Астрахань)Федеральный центр сердечно-сосудистой хирургии (Астрахань)РоссияFederal Center for Cardiovascular Surgery (Astrakhan)Russian FederationНациональный медико-хирургический центр имени Н.И. ПироговаРоссияNational Medical and Surgical Center named after N.I. PirogovRussian Federation202118042021047887Copyright © Кулеш А.А., Демин Д.А., Виноградов О.И., 20212021Кулеш А.А., Демин Д.А., Виноградов О.И.Kulesh A.A., Demin D.A., Vinogradov O.I.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/6093

В статье обсуждаются концепция эмболического инсульта из неустановленного источника и роль аорто-артериальной эмболии в его развитии. Подробно рассмотрены такие потенциальные причины эмболического криптогенного инсульта, как атероматоз аорты, нестенозирующий атеросклероз цервикальных артерий, каротидная сеть и интракраниальный атеросклероз. В рамках обсуждения каждой причины освещены вопросы эпидемиологии, патогенеза, а также современные подходы к диагностике и вторичной профилактике. Диагностический поиск представлен в виде алгоритма. Для выявления аорто-артериальных источников эмболии и определения их клинический значимости требуется развернутое обследование, включающее КТ-ангиографию с прицельной оценкой дуги аорты, чреспищеводную эхокардиографию, МРТ артериальной стенки и транскраниальную микроэмболодетекцию. При выполнении механической тромбэктомии целесообразно проводить гистологическое исследование тромбоэмбола. С учетом того что атеросклероз, как правило, имеет системный характер, поиск возможной причины аортоартериальной эмболии должен быть приоритетным направлением диагностики у  пациентов с  криптогенным инсультом и  поражением других артерий  (коронарных, нижних конечностей). В  отношении вторичной профилактики криптогенного инсульта при наличии потенциальных источников аорто-артериальной эмболии применим принцип «чем эмбологеннее источник, тем агрессивнее профилактика». В арсенал вторичной профилактики входят такие стратегии, как строгий контроль сосудистых факторов риска, достижение целевого артериального давления, кратко- и среднесрочная двойная антитромбоцитарная терапия, а также интенсивная гиполипидемическая терапия. При развитии инсульта на фоне каротидной сети оправдана хирургическая профилактика, эффективность которой при нестенозирующем атеросклерозе требует скорейшей оценки в рандомизированных исследованиях. Каждая рассмотренная потенциальная причина криптогенного инсульта проиллюстрирована клиническим примером.

The article discusses the concept of embolic stroke from an unspecified source and the role of aorto-arterial embolism in its development. Potential causes of embolic cryptogenic stroke such as aortic atheromatosis, non-stenotic atherosclerosis of the cervical arteries, carotid web and intracranial atherosclerosis are discussed in detail. The discussion of each cause covers epidemiology, pathogenesis, and current approaches to diagnosis and secondary prevention. The diagnostic search is presented in the form of an algorithm. To identify aorto-arterial sources of embolism and to determine their clinical significance, a comprehensive examination including CT angiography with targeted assessment of the aortic arch, transesophageal echocardiography, MRI of the arterial wall and transcranial Doppler is required. When mechanical thrombectomy is performed, histological examination of the thromboembolus is advisable. Given that atherosclerosis is usually systemic, the search for a possible cause of aorto-arterial embolism should be a diagnostic priority in patients with cryptogenic stroke and other arterial (coronary, lower extremity) lesions. With regard to secondary prevention of cryptogenic stroke in the presence of potential sources of aorto-arterial embolism, the principle ‘the more embologenic the source, the more aggressive the prevention’ applies. The arsenal of secondary prevention includes strategies such as strict control of vascular risk factors, achieving target blood pressure, short- and medium-term dual antiplatelet therapy, and intensive hypolipidemic therapy. Surgical prophylaxis is warranted for stroke against a carotid background, the efficacy of which in non-stenotic atherosclerosis requires early evaluation in randomised trials. Each potential cause of cryptogenic stroke considered is illustrated by a clinical example.

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