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Криптогенный инсульт. Часть 1: аорто-артериальная эмболия

https://doi.org/10.21518/2079-701X-2021-4-78-87

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Аннотация

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.

Об авторах

А. А. Кулеш
Пермский государственный медицинский университет имени академика Е.А. Вагнера
Россия

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

614000, Пермь, ул. Петропавловская, д. 26



Д. А. Демин
Федеральный центр сердечно-сосудистой хирургии (Астрахань)Федеральный центр сердечно-сосудистой хирургии (Астрахань)
Россия

Демин Дмитрий Алексеевич, врач-невролог

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



О. И. Виноградов
Национальный медико-хирургический центр имени Н.И. Пирогова
Россия

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

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



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Для цитирования:


Кулеш А.А., Демин Д.А., Виноградов О.И. Криптогенный инсульт. Часть 1: аорто-артериальная эмболия. Медицинский Совет. 2021;(4):78-87. https://doi.org/10.21518/2079-701X-2021-4-78-87

For citation:


Kulesh A.A., Demin D.A., Vinogradov O.I. Cryptogenic stroke. Part 1: Aorto-arterial embolism. Meditsinskiy sovet = Medical Council. 2021;(4):78-87. (In Russ.) https://doi.org/10.21518/2079-701X-2021-4-78-87

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ISSN 2079-701X (Print)
ISSN 2658-5790 (Online)