Криптогенный инсульт. Часть 2: парадоксальная эмболия

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.

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