Криптогенный инсульт. Часть 4: антифосфолипидный синдром и рак

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.

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