medsovetМедицинский СоветMeditsinskiy sovet = Medical Council2079-701X2658-5790REMEDIUM GROUP Ltd.10.21518/ms2023-186medsovet-7637Research ArticleЦЕРЕБРОВАСКУЛЯРНЫЕ ЗАБОЛЕВАНИЯCEREBROVASCULAR DISEASESКриптогенный инсульт. Часть 4: антифосфолипидный синдром и ракCryptogenic stroke. Part 4: Antiphospholipid syndrome and cancerhttps://orcid.org/0000-0001-6061-8118КулешА. А.KuleshA. A.

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

614000, Пермь, ул. Петропавловская, д. 26

614107, Пермь, ул. КИМ, д. 2

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

26, Petropavlovskaya St., Perm, 614990

2, KIM St., Perm, 614107

aleksey.kulesh@gmail.comhttps://orcid.org/0000-0003-3124-2443БелопасоваА. В.BelopasovaA. V.

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

125367, Москва, Волоколамское шоссе, д. 80

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

80, Volokolamskoe Shosse, Moscow, 125367

belopasova@neurology.ruhttps://orcid.org/0000-0003-2670-4172ДеминД. А.DeminD. A.

Демин Дмитрий Алексеевич, врач-невролог

414004, Астрахань, ул. Покровская Роща, д. 4

Dmitry A. Demin, Neurologist

4, Pokrovskaya Roshcha St., Аstrakhan, 414011

demin2404@mail.ruhttps://orcid.org/0000-0001-5679-4100МехряковС. А.MekhryakovS. A.

Мехряков Сергей Александрович, к.м.н., врач ультразвуковой диагностики

614107, Пермь, ул. КИМ, д. 2

Sergey A. Mekhryakov, Cand. Sci. (Med.), Ultrasound Diagnostics Doctor

2, KIM St., Perm, 614107

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

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

614000, Пермь, ул. Петропавловская, д. 26

614107, Пермь, ул. КИМ, д. 2

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

26, Petropavlovskaya St., Perm, 614990

2, KIM St., Perm, 614107

ilarievna@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, Москва, ул. Нижняя Первомайская, д. 70

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

70, Nizhnyaya Pervomayskaya St., Moscow, 105203

olvinog1975@gmail.comПермский государственный медицинский университет имени академика Е.А. Вагнера; Городская клиническая больница № 4РоссияVagner Perm State Medical University; City Clinical Hospital No. 4Russian FederationНаучный центр неврологииРоссияResearch Center of NeurologyRussian FederationФедеральный центр сердечно-сосудистой хирургииРоссияFederal Center for Cardiovascular SurgeryRussian 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 Federation20232107202301021–31Copyright © Кулеш А.А., Белопасова А.В., Демин Д.А., Мехряков С.А., Сыромятникова Л.И., Виноградов О.И., 20232023Кулеш А.А., Белопасова А.В., Демин Д.А., Мехряков С.А., Сыромятникова Л.И., Виноградов О.И.Kulesh A.A., Belopasova A.V., Demin D.A., Mekhryakov S.A., Syromyatnikova L.I., 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/7637

Криптогенный эмболический инсульт (embolic strokes of undetermined source, ESUS) представляет собой промежуточный диагноз у пациентов с неизвестной этиологией инсульта и подразумевает отсутствие больших источников кардиоэмболии и значимых экстра- и интракраниальных стенозов и вероятный эмболический патогенез инфаркта головного мозга. В предыдущих частях статьи мы обсудили вопросы диагностики и вторичной профилактики при ESUS на фоне потенциальных аорто- аортальных источников эмболии, парадоксальной эмболии и предсердной кардиопатии. В рамках настоящей публикации рассмотрены вопросы эпидемиологии, патогенеза, диагностики и вторичной профилактики ишемического инсульта на фоне антифосфолипидного синдрома (АФС) и рак-ассоциированного инсульта (РАИ). Оба механизма инсульта связаны с гиперкоагуляцией, часто проявляются многоочаговым поражением коры головного мозга и отвечают на терапию антикоагулянтами. Тогда как АФС следует подозревать в первую очередь у молодых женщин с патологией беременности, артериальными и венозными тромбозами, а также с сетчатым ливедо (livedo reticularis) гроздевидным (racеmosa), РАИ не имеет специфической клинической картины, однако может манифестировать рассеянными кортикальными инфарктами (симптом трех бассейнов) в сочетании с повышением уровня Д-димера. При подозрении на АФС необходим соответствующий гематологический скрининг с последующим применением Сиднейских диагностических критериев. Диагноз возможного РАИ часто требует проведения чреспищеводной эхокардиографии (исключение небактериального тромбэндокардита) и онкопоиска. Вторичная профилактика АФС заключается в назначении варфарина с целевым МНО 2,0–3,0. При РАИ используются антикоагулянты, при этом выбор препарата и дозы определяются балансом тромботических / тромбоэмболических и геморрагических рисков.

Cryptogenic embolic stroke (embolic strokes of undetermined source, ESUS) is an intermediate diagnosis in patients with unknown etiology of stroke and implies the absence of large sources of cardioembolism and significant extra- and intracranial stenoses and probably embolic pathogenesis of cerebral infarction. In the previous parts of the article, we discussed the issues of diagnosis and secondary prevention of ESUS with underlying potential aortoaortic sources of embolism, paradoxical embolism and atrial cardiopathy. This article discusses the issues of epidemiology, pathogenesis, diagnosis and secondary prevention of ischemic stroke with underlying antiphospholipid syndrome (APS) and cancer-associated stroke (RAI). Both mechanisms of stroke are associated with hypercoagulability, often manifest as multifocal cortical brain lesions, and respond to anticoagulant therapy. While APS should be suspected primarily in young women with pathology of pregnancy, arterial and venous thrombosis, as well as livedo reticularis (racemosa), RAI does not have a specific clinical picture, but can manifest as diffuse cortical infarcts (symptom of three pools) combined with increased D-dimer level. If APS is suspected, appropriate haematological screening is required, followed by the use of the Sydney diagnostic criteria. Possible diagnosis of RAI often requires transesophageal echocardiography (ruling out non-bacterial thromboendocarditis) and oncological screening. Secondary prevention of APS consists in prescribing warfarin with the target international normalized ratio (INR) of 2.0 to 3.0. RAI is treated with anticoagulants, but the choice of a drug and dose is determined by the balance between thrombotic/thromboembolic and hemorrhagic risks.

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