Криптогенный инсульт. Часть 1: аорто-артериальная эмболия

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.

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