medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/2079-701X-2021-19-16-33medsovet-6524Research ArticleЦЕРЕБРОВАСКУЛЯРНЫЕ ЗАБОЛЕВАНИЯCEREBROVASCULAR DISEASESКриптогенный инсульт. Часть 2: парадоксальная эмболияCryptogenic stroke. Part 2: paradoxical embolismhttps://orcid.org/0000-0001-6061-8118КулешА. А.KuleshA. A.

Кулеш Алексей Александрович, д.м.н., доцент, профессор кафедры неврологии и медицинской генетики

614000, Россия, Пермь, ул. Петропавловская, д. 26

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

26, Petropavlovskaya St., Perm, 614990, Russia

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

Демин Дмитрий Алексеевич, врач-невролог

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

Dmitry A. Demin, Neurologist

4, Pokrovskaya Roscha St, Astrakhan, 414011, Russia

demin2404@mail.ruhttps://orcid.org/0000-0003-3124-2443БелопасоваА. В.BelopasovaA. V.

Белопасова Анастасия Владимировна, к.м.н., научный сотрудник, 3-е неврологическое отделение

125367, Россия, Москва, Волоколамское шоссе, д. 80

Anastasia V. Belopasova, Cand. Sci. (Med.), Researcher, 3rd Neurological Department

80, Volokolamskoe Shosse, Moscow, 125367, Russia

belopasova@neurology.ruhttps://orcid.org/0000-0001-5679-4100МехряковС. А.MekhryakovS. A.

Мехряков Сергей Александрович, врач ультразвуковой диагностики

614107, Россия, Пермь, ул. КИМ, д. 2

Sergey A. Mekhryakov, Doctor of Ultrasound Diagnostics

2, KIM St., Perm, 614107, Russia

heartolog@gmail.comhttps://orcid.org/0000-0002-3847-9366ВиноградовО. И.VinogradovO. I.

Виноградов Олег Иванович, д.м.н., профессор, заведующий кафедрой неврологии с курсом нейрохирургии

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

Oleg I. Vinogradov, Dr. Sci. (Med.), Professor, Head of Department of Neurology with Neurosurgery Course

70, Nizhnyaya Pervomayskaya St., Moscow, 105203, Russia

olvinog1975@gmail.comhttps://orcid.org/0000-0002-8305-1115СыромятниковаЛ. И.SyromyatnikovaL. I.

Сыромятникова Людмила Илариевна, д.м.н., профессор кафедры пропедевтики внутренних болезней №1

614000, Россия, Пермь, ул. Петропавловская, д. 26

Lyudmila I. Syromyatnikova, Dr. Sci. (Med.), Professor of the Department of Propedeutics of Internal Diseases No. 1,

26, Petropavlovskaya St., Perm, 614990, Russia

ilarievna@gmail.comhttps://orcid.org/0000-0002-7119-2340ЗеньковА. А.ZiankouA. A.

Зеньков Александр Александрович, д.м.н., сердечно-сосудистый хирург

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

Aliaksandr A. Ziankou, Dr. Sci. (Med.), Cardiovascular Surgeon

4, Pokrovskaya Roscha St, Astrakhan, 414011, Russia

Zenkov_Al@rambler.ruПермский государственный медицинский университет имени академика Е.А. ВагнераРоссияVagner Perm State Medical UniversityRussian FederationФедеральный центр сердечно-сосудистой хирургии (Астрахань)РоссияFederal Center for Cardiovascular Surgery (Astrakhan)Russian FederationНаучный центр неврологииРоссияResearch Center of NeurologyRussian FederationГородская клиническая больница № 4РоссияCity Clinical Hospital No. 4Russian FederationНациональный медико-хирургический центр имени Н.И. ПироговаРоссияNational Medical and Surgical Center named after N.I. PirogovRussian Federation2021301120210191633Copyright © Кулеш А.А., Демин Д.А., Белопасова А.В., Мехряков С.А., Виноградов О.И., Сыромятникова Л.И., Зеньков А.А., 20212021Кулеш А.А., Демин Д.А., Белопасова А.В., Мехряков С.А., Виноградов О.И., Сыромятникова Л.И., Зеньков А.А.Kulesh A.A., Demin D.A., Belopasova A.V., Mekhryakov S.A., Vinogradov O.I., Syromyatnikova L.I., Ziankou 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/6524

Криптогенный инсульт – подтип инсульта, связанный с гетерогенной группой патогенетических механизмов, оставшихся нераскрытыми в результате проведения расширенного диагностического поиска, который устанавливается у каждого 3–4 пациента с ишемическим инсультом. Парадоксальная эмболия служит важной причиной криптогенного инсульта и ТИА у пациентов молодого возраста. Она может реализоваться через открытое овальное окно (ООО), дефект межпредсердной перегородки (ДМПП) и легочную артериовенозную мальформацию (ЛАВМ). При сборе анамнеза у пациентов с подозрением на парадоксальную эмболию следует учитывать факторы, связанные с маневром Вальсальвы, тромбоз глубоких вен/ТЭЛА или предрасполагающие к ним состояния или ситуации, а также симптомы наследственной геморрагической телеангиэктазии (телеангиэктазии кожи и слизистых оболочек, геморрагический синдром) и ЛАВМ (одышка, кровохарканье). При подозрении на парадоксальную эмболию необходимо проведение ступенчатого диагностического поиска, включающего транскраниальную допплерографию с пузырьковой пробой, чреспищеводную эхокардиографию с контрастированием, а также КТ-ангиопульмонографию. Диагностика релевантных клинических состояний подразумевает поиск предсердных тахиаритмий, тромбоза глубоких вен и тромбофилии. Тогда как патогенетическая роль ДМПП и ЛАВМ в развитии эмболического криптогенного инсульта не подлежит сомнению, определение клинической значимости ООО должно проводиться с учетом ряда факторов, в числе которых наличие тромбоза глубоких вен/ТЭЛА, выраженность право-левого шунта, присутствие аневризмы МПП, результат шкалы RoPE и факт выявления тромбофилии. Метод вторичной профилактики ишемического инсульта или ТИА на фоне ООО должен подбираться индивидуально в зависимости от клинической значимости аномалии, коморбидной патологии: эндоваскулярная окклюзия, антикоагулянтная или антитромбоцитарная терапия. Вторичная профилактика на фоне ДМПП и ЛАВМ включает такие хирургические методы, как эндоваскулярную окклюзию или открытое хирургическое вмешательство с последующим мониторингом их эффективности.

Cryptogenic stroke (CS) is defined as a subtype of stroke associated with a heterogeneous group of pathogenetic mechanisms that remained undetermined in the course of advanced diagnostic research. One third or fourth of the ischemic strokes is cryptogenic. Paradoxical embolism is considered the important cause of cryptogenic stroke and transient ischaemic attack (TIA) in young patients. It may occur via the following: patent foramen ovale (PFO), atrial septal defect (ASD), and pulmonary arteriovenous malformation (PAVM). When interviewing patients with suspected paradoxical embolism to obtain their health history, a practitioner should consider factors associated with Valsalva maneuvers, deep vein thrombosis/PE or predisposing conditions or situations, as well as symptoms of hereditary hemorrhagic telangiectasia (telangiectasia of the skin and mucous membranes, hemorrhagic syndrome) and pulmonary arteriovenous malformations (PAVMs) (shortness of breath, hemoptysis). If paradoxical embolism is suspected, it is necessary to conduct a stepwise diagnostic search, including transcranial Doppler ultrasound with bubble test, contrast-enhanced transesophageal echocardiography, and CT angiopulmonography. Diagnosis of relevant clinical conditions involves a search of atrial tachyarrhythmias, deep vein thrombosis, and thrombophilia. As the pathogenetic role of ASD and PAVMs in the development of embolic cryptogenic stroke is beyond doubt, the clinical significance of PFO should be determined taking into account several factors, including the presence of deep vein thrombosis/PE, the severity of the right-left shunt, the presence of ASD, the RoPE score, and detection of thrombophilia. The secondary prevention techniques of ischemic stroke or TIA with underlying PFO should be selected on a case-by-case basis, depending on the clinical significance of the anomaly, comorbid pathology, life expectancy of the patient: endovascular occlusion, anticoagulant or antiplatelet therapy. The secondary prevention with underlying ASD and LAVM includes surgical techniques such as endovascular occlusion or open surgery followed by monitoring of their effectiveness.

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