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Introduction. Intravenous thrombolysis (IT) is the primary method of reperfusion therapy for ischemic stroke. Over the past couple of years, there has been a global trend towards the predominant use of the bolus forms of thrombolytic drugs that is caused by necessity to increase the reperfusion therapy rate to achieve its best outcomes.Aim. To evaluate the efficacy and safety of the use of non-immunogenic staphylokinase for IT in ischemic stroke in real-world clinical practice of the regional vascular center.Materials and methods. The clinical outcomes of the cohort of 50 patients who underwent IT with non-immunogenic staphylokinase were analysed.Results. The age of the patients ranged from 46 to 94 years and averaged 71.8 ± 10.0 years; 22% of patients were over 80 years of age. The NIHSS score at admission varied from 3 to 23 scores and averaged 11 (8-14) scores. 36% of patients had large artery occlusions. 14% of patients received a step-wise reperfusion therapy. The median door-to-needle time was 23 (18-26) minutes. 52% of patients didn’t develop any infarction area during control neuroimaging. 62% of patients required no further rehabilitation. Hospital mortality was 12%. 18% of patients developed hemorrhagic conversion mainly in the form of hemorrhagic infarction. 1 patient had a symptomatic hemorrhagic conversion. Major bleeding and angioedema were not observed.Conclusion. The analysis of 50 consecutive cases of IT in ischemic stroke using non-immunogenic staphylokinase indicates the high efficiency and safety of this method of reperfusion therapy.

Determining the potential mechanisms underlying cryptogenic ischemic stroke is essential to guide diagnostic discovery and personalize secondary prevention.Purpose is to study the phenotypes of embolic stroke of undetermined source (ESUS) based on ultrasound diagnosis and determination of the serum concentration of pro-natriuretic N-terminal peptide B-type (N-Terminal Pro-brain Natriuretic Peptide, NT-proBNP).Materials and methods. 141 patients with ESUS were examined. In addition to the standard examination aimed at fi nding the cause of stroke, the functional characteristics of the left atrium were assessed using the emptying fraction (left atrial emptying fraction, LAEF) and the functional index (left atrial function index, LAFI), and the concentration of NT-proBNP in blood serum was also measured.Results. The most common potential sources of embolism were atherosclerotic plaques in the stroke-associated carotid artery with stenosis in 30–49% (31.9% of patients) and atrial cardiopathy with a decrease in LAEF < 51.8% (24.8% of patients). An analysis of combinations of potential sources showed that 46.1% of patients had a negative phenotype, 21.3% of patients had a cardiac phenotype, 19.1% of patients had an atherosclerotic phenotype, and 13.5% of the examined patients had a mixed phenotype. Patients with a cardio-atherosclerotic phenotype diff ered from patients with a negative phenotype by higher disability on the Rankin scale at discharge from the hospital.Conclusion. The main potential embolic sources in patients with ESUS are non-stenosing carotid atherosclerosis and atrial cardiopathy with decreased LAEF. Cardiac and atherosclerotic phenotypes are determined in a quarter of patients, a mixed phenotype is found in every seventh patient, while in almost half of the patients no sources of embolism are found.

Introduction. According to foreign studies, the frequency of asymptomatic deep vein thrombosis (DVT) in the acute period of stroke varies from 10 to 75%, clinically obvious — from 2 to 10%. DVT is a life-threatening complication as it can lead to the development of pulmonary embolism (PE).Purpose of the study: to identify predictors of DVT development in the lower extremities in patients with stroke according to the registry of the Regional Vascular Center (RVC).Materials and methods. 100 patients with stroke who were admitted to the wards/intensive care unit of the RVC from November to December 2021 were examined. In addition to the standard examination, all patients underwent duplex scanning of the veins of the lower extremities upon admission and on the 7th day of inpatient treatment.Results. The incidence of DVT was 13%. Compared with patients without DVT, patients with thrombosis were characterized by higher median values of age (77 vs 67 years, p = 0.015), time from stroke to hospital admission (24 vs 5 hours, p = 0.026), stroke severity by NIHSS score at admission (16 vs 5 points, p = 0.006) and completion of the first stage of treatment (10 vs 3 points, p = 0.010), movement disorders in the leg according to the Medical Research Council scale (4 vs 1 points, p = 0.011) and IMPROVE-VTE scales (4 vs 2 points, p < 0.001). In half of patients with DVT, thrombosis occurred already at admission to the hospital, in the rest it occurred during treatment. In a quarter of patients, thrombosis involved the proximal veins and was complicated by the development of PE in one patient, the rest had distal DVT. In all cases, DVT developed in the paretic limb. In all patients, thrombosis was initially regarded as asymptomatic and was diagnosed only by duplex scanning of the veins. The most significant risk factors for developing DVT in the acute period of stroke were age 64 years and over (OR = 8.1), stroke severity on the NIHSS scale at admission of 6 points and above (OR = 5.6), time to admission from 10 hours or more (OR = 3.8), leg strength not more than 3 points (OR = 4.5) and an IMPROVE-VTE score of 3 points or more (OR = 9.5). When building a logistic regression model using the identified risk factors, accuracy values were obtained equal to 83% and 85% for the training and test samples, respectively.Conclusion. DVT is observed in 13% of patients in the acute period of stroke and is associated with the age of patients, the severity of stroke and movement disorders, the time from the development of symptoms to hospital admission, and the risk of venous thromboembolic complications according to the IMPROVE-VTE scale.

Atrial cardiopathy (AC) and silent atrial fibrillation (AF) are potential causes of embolic cryptogenic stroke (embolic stroke of undetermined source, ESUS) timely diagnosis of which can significantly change the direction of secondary prevention and reduce the risk of repeated brain catastrophe. The article discusses clinical and radiological markers of cardioembolism, the concept of atrial cardiopathy, its electrocardiographic, echocardiographic and serum markers, as well as the possibility of drug prophylaxis of recurrent stroke. The most applicable AC features in daily operation are the ECG data (p-wave terminal force in lead V1 > 5000 μV x ms, supraventricular extrasystoles and advanced interatrial block), 24-hour ECG monitoring (≥ 480 supraventricular extrasystoles per 24-hour, paroxysms of supraventricular tachycardia ≥ 20 complexes), transthoracic (diameter of left atrium > 40 mm, index of diameter of left atrium ≥ 3 cm/m2, index of volume of left atrium > 34 ml/m2) and transesophageal echocardiography (spontaneous echo contrast phenomenon, blood flow rate in LA appendage 250 pg/ml. An individual, interdisciplinary decision to prescribe an anticoagulant when combined: (1) the presence of structural and functional AC markers, (2) cardioembolic pattern of a cerebral infarction or intracranial artery occlusion by visualization data and (3) high thromboembolic risk and probability of detection of AF on assessment scales (CHA2DS2-VASc, AF-ESUS and C2HEST). The greatest benefit of prescribing anticoagulant therapy can be obtained by patients with recurrent ESUS in whom sufficient secondary prevention and expressed AC, typical cardioembolism imaging pattern and high risk of thromboembolic events have already been achieved.

The article presents a clinical example of using the diagnostic algorithm for identifying the criteria for atrial cardiopathy in a patient with cryptogenic stroke. This clinical case required prolonged ECG monitoring, detection of subclinical atrial fibrillation, and subsequent collegial establishment of indications for initiation of anticoagulant therapy taking into account the high risk of recurrent stroke.

Pulmonary arteriovenous malformation (PAVM) is considered a rare cause of ischaemic stroke in young patients. In this article, we present a case series of 5 patients with PAVM-associated ischaemic stroke. We discuss pathophysiology, clinical presentation, diagnostic approaches, and secondary prevention. In addition, two of the aforementioned cases are provided in detail: the one of 32-year-old female with ischaemic stroke associated with sporadic PAVM, the latter being treated with embolization, and the one of 24-year-old male with hereditary hemorrhagic telangiectasia (HHT) who developed PAVM-associated ischaemic stroke, who was treated with intravenous thrombolytic therapy and mechanical thrombectomy on admission, followed by video-assisted thoracoscopic PAVM resection.

Goal. Consider the management of patients with effort thrombosis (Paget-Schretter syndrome).The article presents the modern vision of the problem of effort thrombosis. This review is aimed at describing the epidemiology, pathophysiology, diagnosis and treatment of patients with Paget-Schretter syndrome. SPS occurs spontaneously, as a rule, in young, healthy and active patients aged 20-30 years after strenuous physical activity. The ratio of men and women is 2:1, recently there has been a growing trend among women. The main complaints of patients with SPS include swelling of the affected limb, discomfort when moving the affected arm, pain and heaviness when trying to raise the arm up. When examining these patients, attention is paid to hyperemia of the skin or their cyanotic nature, pasty limbs, as well as an enhanced venous pattern on the shoulder, the so-called Arshel sign. The diagnosis is based on the data of anamnesis, physical examination, the “gold standard of diagnostics” – ultrasound examination of veins, the sensitivity and specificity of which is 70-100%. The first step in the diagnosis can be the evaluation of the D-dimer, with its negative values, the SPSH is rejected. With an obvious clinic and controversial results of serial ultrasound examinations, other imaging methods are used, such as computed contrast tomography, magnetic resonance imaging, the diagnostic value of which is especially significant in occlusive venous thrombosis.SPS differs not only from DVT of the lower extremities, but also from secondary DVT of the upper extremities, which determines the peculiarities of management of this category of patients, including surgical treatment aimed at preventing subclavian vein compression in the future. The article summarizes the experience in the management of patients with blood thrombosis.

We present a case report of a middle-aged patient with a rare sinus venosus atrial septal defect (ASD) and ischemic stroke that developed due to paradoxical embolism. Occlusion of the anterior cerebral artery led to a stroke with cognitive impairment, acalculia, and apraxia. Diagnostic ultrasound features of this anomaly in suspected cases are discussed. In the presented case, verification of the stroke cause became possible due to the contrast-enhanced computed tomography of the heart. ASD detection made it possible to refer the patient to the surgical treatment necessary to prevent both recurrent cerebral accidents and the progression of pulmonary hypertension, and the prevention of the development of right ventricular heart failure.

In young patients, the causes of ischemic stroke (IS) are substantially different from those in older patients. Understanding the causes of the disease in patients younger than 45 years is needed to elaborate examination algorithms used in the country’s vascular departments.Objective: to present the nosological characteristics of IS in patients younger than 45 years according to the hospital register of the regional vascular center.Patients and methods. The data of the hospital register of the neurological unit for patients with acute cerebral circulatory disorders, who were in the Perm Territorial Vascular Center, City Clinical Hospital Four, in 2014 to 2020, were analyzed. The analysis included 126 patients under the age of 45 years with IS verified by magnetic resonance imaging.Results and discussion. The pathogenetic subtypes of IS according to the TOAST criteria were large artery atherosclerosis [n=10 (7.9%)], cardioembolism [n=27 (21.4%)], small vessel disease [n=15 (11.9%)], IS of other determined etiology [n=23 (18.3%)], and IS of undetermined etiology [n=51 (40.5%)]. After excluding incomplete examination cases (n=29), the most common causes of IS were cardiac embolism (patent foramen ovale, atrial septal defect, prosthetic valves, acute infective endocarditis, and chronic cardiac aneurysm) (27.8%), large artery disease (atherosclerosis and unspecified arteriopathy) (21.6%), small artery disease (15.5%), as well as cervical and cerebral artery dissection (10.3%). Cryptogenic stroke was observed in 13% of patients. There was a preponderance of cryptogenic IS in the age subgroup of 21–25 years, cardiac embolism (mainly patent foramen ovale) in the subgroup of 26–35 years; the proportions of cardiac embolism, large and small artery diseases, and dissections were comparable in the subgroup of 36–40 years; large and small artery diseases prevailed in the subgroup of 41–44 years.Conclusion. The most common causes of IS in 18–44-year-old patients are cardiac embolism (mainly through the mechanism of paradoxical embolism) and large artery disease, including dissection. The etiology of IS depended on age: cardiac embolism prevailed in the younger age range, whereas large and small artery diseases were dominant in the older age range.

The paper describes three clinical cases of ischemic stroke (IS) in the presence of patent foramen ovale (PFO) in young women. The first patient has experienced two episodes of focal neurological deficit related to physical exercise. A cerebellar stroke focus was visualized by brain magnetic resonance imaging (MRI). During emotional stress, the second patient having migraine with aura developed transient weakness in the right extremities, and a stroke focus was verified in the left parietal lobe. The third patient suddenly had facial asymmetry and left arm numbness after awakening in the morning. The patient underwent intravenous thrombolysis; control brain MRI revealed a right parietal lobe stroke. Standard examinations of all the patients established no cause of IS. Transcranial Doppler with a bubble test and subsequent transesophageal echocardiography revealed PFO that was regarded as clinically significant. Endovascular occlusion was successfully accomplished in all the patients. The paper discusses the problems of secondary prevention of PFO-related stroke and proposes an algorithm for the diagnosis and treatment of this disease.

Patent foramen ovale (PFO) is an important cause of embolic cryptogenic stroke (ECS) in young patients. The main mechanism in this case is paradoxical embolism (PE), the basis for which is a right-to-left (R-L) shunt. Objective: to comparatively characterize patients who have undergone ECS, with and without an R-L shunt, as evidenced by transcranial Doppler with the bubble test (TCD-BT). Patients and methods . In 40 patients with acute ECS, an R-L shunt was sought using TCD-BT, followed by transesophageal echocardiography (TEE). The left atrial volume index (LAVI) was additionally calculated. Brain damage was analyzed by probabilistic mapping of foci according to magnetic resonance imaging. Results and discussion. The mean age of the examined patients was 51.5 (39.5–60.0) years; of them there were 22 women and 18 men. An RL shunt was detected in 24 (60.0%) of patients with cryptogenic embolism that was mainly grades 2 and 3 (41.0 and 35.0%). TEE could visualize PFO (1.0 to 5.5 mm in size) in 16 (40%) patients and atrial septal aneurysm in 3 (7.5%). PFO was not found in 5 patients with positive results of TCD-BT, which may suggest that there is either a pulmonary shunt or a false-negative TEE. The patients with an R-L shunt versus those without an R-L-shunt showed lower LAVIs (23.9 and 26.5 mL/m2) (p=0.016). This fact may additionally confirm the causative role of PFO in the development of stroke, whereas higher LAVIs in the non R-L shunt subgroup should alert to the presence of atrial cardiopathy and initiate an appropriate diagnostic search for latent atrial fibrillation. According to the presence or absence of an R-L shunt, the groups did not significantly differ in gender, age, and clinical characteristics of the stroke. In patients with PFO, a lesion focus was most commonly localized in the middle cerebral artery bed (35.3%), cerebellum (23.5%), and posterior cerebral artery (17.6%). Five (29.0%) patients were ascertained to have several foci of acute stroke. There was a trend towards the larger size of cerebral infarction foci and their specific localization in the vertebrobasilar bed in PE, which determined the high (35.3%) incidence of ataxia with the onset of the disease. Conclusion. PE causes ECS in 60.0% of cases. The distinctive feature of patients with an R-L shunt is lower LAVIs and a trend towards the larger size of cerebral infarction foci and their specific localization in the vertebrobasilar bed.

Atherothrombotic stroke (ATI), cardioembolic stroke (CEI) and lacunar stroke (LI) are the main pathogenetic variants of ischemic stroke and differ not only in the final mechanism of formation of the ischemic focus, but also in the systemic disorders underlying them. Material and methods. 384 patients were examined in acute ischemic stroke using standard methods. All patients were evaluated for total cardiovascular risk with the use of scales ASCORE, CHA2DS2-VASc, Essen and the scale of recurrent stroke . Results. ATI was diagnosed in 268 (70%) patients, 70 (18%) patients, 46 (12%) patients. The highest rate on the scale of relapse of stroke is typical for patients with CEI, the lowest - for patients with LI. Patients with ATI had a high score on THE ascore scale. The highest rate on the scale CHA2DS2-VASc was observed in patients with CEI, the lowest - in patients with LI. Other indicators informative for differentiation of the studied types of AI are age, gender, Smoking, congestive heart failure, lipid profile, presence and size of cerebral infarction on computer tomogram on admission, involvement of vertebrobasilar pool, hemorrhagic transformation of the lesion, the thickness of the intima - media, degree of stenosis of internal carotid arteries, stenosis of intracranial arteries, cardiac ejection fraction, time from stroke to admission to hospital, hemiplegia, neglect syndrome, speech disorder, as well as neurological deficit on the NIHSS scale. Discussion. Patients with studied pathogenetic variants of ischemic stroke differed in severity and representation of cardiovascular risk factors, clinical picture and outcome of the disease, which confirms the point of view of phenotypic independence of ATI, KEI and LEE, probably due to genetic features.

Perfusion computed tomography (PCT) is increasingly used to diagnose ischemic stroke (IS), as well as to identify candidates for thrombolytic therapy (TLT). The feasibility of using this technique in all patients within the therapeutic window has not yet been established. Objective: to investigate cerebral blood flow according to PCT findings and its relationship to clinical and instrumental indicators and functional status of patients who had received TLT in the acute period of IS. Patients and methods. 62 patients with acute IS who had received TLT were examined. All the patients underwent clinical, laboratory, and instrumental examinations and PCT, by assessing cerebral blood volume (CBV), cerebral blood flow (CBF), and mean transit time (MTT) in 10 brain regions in accordance with the Alberta Score Program Early CT Score (ASPECTS). The total result of perfusion ASPECTS was calculated separately for CBV, CBF and MTT, as well as combinations of these parameters. The penumbra size was calculated as CBV minus MTT (CBV - MTT) ASPECTS, the infarct core size was measured as CBV + MTT ASPECTS. Results. There was an increase in MTT in most regions of interest of the affected hemisphere as compared to the intact one and a predominance of reversible perfusion disorders. The averaged penumbra size constituted three zones according to ASPECTS. No relationship was found between ASPECTS scores and time after the onset of symptoms prior to hospital admission. Perfusion parameters, particularly penumbra size (CBV - MTT), were associated with the degree of stenosis in the contralateral common carotid artery, body mass index, and blood triglyceride level. Cerebral blood flow indices were also influenced by red blood cell counts and heart ejection fraction. The scores of the perfusion scales were correlated with those of the non-contrast scale. The data of the investigated ASPECTS variants correlated with the level of neurological deficit in patients, its course, and the functional outcome of acute IS. Conclusion. The perfusion variants of ASPECTS have a high predictive value for patients' neurologic and functional status upon completion of the first treatment stage. The penumbra size (CBV - MTT ASPECTS) is a marker for the expected regression of neurological impairment during TLT. The infarct core size (CBV + MTT ASPECTS) determines the degree of neurologic deficit at a patient's discharge.

To evaluate neurological and functional outcomes of early stage of ischemic stroke, their determining factors and predictors of hemorrhagic transformation in patients who received thrombolysis.A retrospective analysis of 147 patients, who underwent thrombolysis, and 127 patients, matched for basic parameters, who did not receive thrombolysis, was performed. Anamnesis, results of clinical examination, a spectrum of laboratory-instrumental parameters were evaluated. Functional status was assessed at discharge from the hospital using the Rivermead mobility index and the modified Rankin scale. Along with standard computed tomography (CT) at admission and after 24h, 73 patients receiving thrombolysis underwent CT-perfusion examination.The insufficient number of patients (37%) are admitted to a hospital in the first 2 h after stroke. The high prevalence of cardioembolic stroke and aphasia disorders in patients treated with thrombolysis was identified compared to the control group. CT revealed acute cerebral infarction in 14% of patients admitted within 2h. CT-perfusion examination determined brain ischemia only in half of patients. There was a low prevalence of symptom hemorrhagic transformation (0.7%). Thrombolysis was correlated with the higher rate of good functional outcomes of acute stroke, reduced neurological deficit, better mobility at discharge and shorter duration of the first rehabilitation period. Age, smoking, Rankin scale score at baseline, acute infarction on the primary CT, pathogenetic variant of stroke, myocardial hypertrophy, atherosclerosis of carotid arteries and volume of MRI lesions were the main factors associated with the efficacy of thrombolysis. The main predictors of hemorrhagic transformation were the severity of stroke, glomerular filtration rate, atrial fibrillation, treatment with antiaggregants before admission and hemispheric stroke.The analysis has demonstrated the safety and efficacy of thrombolysis in ischemic stroke in real clinical practice of a regional Vascular center.Цель исследования. Оценить неврологические и функциональные исходы острого периода ишемического инсульта (ИИ), детерминирующие их факторы и предикторы геморрагической трансформации в когорте пациентов, которым была выполнена тромболитическая терапия (ТЛТ). Материал и методы. Ретроспективно проанализированы данные 147 пациентов, которым проводилась ТЛТ, в сравнении с сопоставимой по основным параметрам когортой из 127 больных без ТЛТ. Оценивались особенности анамнеза, результаты клинического обследования, лабораторно-инструментальные показатели. Функциональный статус при выписке оценивался при помощи индекса мобильности Ривермид и модифицированной шкалы Рэнкина. Помимо стандартной КТ при поступлении и через 1 сут, 73 пациентам с ТЛТ было проведено перфузионное КТ-исследование (ПКТ). Результаты. Недостаточное число больных (37%) поступают в стационар в первые 2 ч от развития симптомов. Отмечена высокая частота встречаемости кардиоэмболического инсульта и афатических нарушений среди пациентов с ТЛТ в сравнении с группой контроля. У 14% больных, несмотря на поступление в пределах допустимого интервала, отмечался острый инфаркт мозга по данным КТ. По данным ПКТ зона ишемии мозга определялась лишь у 50% больных. Обращала на себя внимание низкая частота развития симптомной геморрагической трансформации (0,7%). Проведение ТЛТ было сопряжено с ростом встречаемости хорошего функционального исхода острого периода инсульта, уменьшением тяжести неврологического дефицита, большей мобильностью при выписке и укорочением продолжительности первого этапа реабилитации. Основными факторами, связанными с эффективностью ТЛТ, явились возраст, курение, исходный результат шкалы Рэнкина, наличие или отсутствие острого инфаркта на первичной КТ, патогенетический вариант инсульта, гипертрофия миокарда, атеросклероз сонных артерий и размер очага по МРТ. Основными предикторами геморрагической трансформации на фоне ТЛТ являются тяжесть инсульта, снижение скорости клубочковой фильтрации, наличие фибрилляции предсердий и прием антиагрегантов до поступления, а также полушарный инсульт. Вывод. Проведенный анализ продемонстрировал безопасность и эффективность ТЛТ при ИИ в реальной клинической практике регионального сосудистого центра.

To study characteristics of the acute stage of ischemic stroke (IS) basing on the data of a hospital register of the Perm Regional vascular center and to assess the efficacy and safety of the drug cellex in patients with IS.Authors have analyzed the group of 128 patients with MRI-confirmed acute ischemic lesion. The subgroup of 40 patients, which beside the basic therapy received cellex in dose of 0.1 mg during 10 days, was randomized.The following data were analyzed: gender and age, prevalence of risk factors, primary prevention, time before admission, clinical presentations, results of instrumental diagnostic methods, pathogenic structure of stroke, use of intravenous thrombolysis, regimens of secondary prevention, functional outcome and its predictors.The group of patients was characterized by the high prevalence of risk factors, insufficient primary prevention, prolonged time before the admission, low rate of thrombolysis use and significant prevalence of large artery disease associated with stroke. The main independent predictors of low mobility level at discharge were severe neurological deficit on admission, cognitive impairment and age. Patients treated with cellex were characterized by the lower level of neurologic deficit, higher mobility and better global cognitive status in comparison with controls.Цель исследования. Изучение особенностей острого периода ишемического инсульта по данным регистра Пермской городской клинической больницы и оценка эффективности и безопасности применения препарата целлекс. Материал и методы. Использовали регистр Пермской городской больницы #4. Была изучена выборка из 128 больных с инсультом. Наличие острого ишемического очага было подтверждено данными магнитно-резонансной томографии. Методом случайного отбора была сформирована группа из 40 человек, которым дополнительно к базисной терапии был назначен препарат целлекс в дозе 0,1 мг в течение 10 дней. Результаты и заключение. На основании данных больничного регистра были выделены факторы риска, клинические особенности и краткосрочные исходы острого периода инсульта. Пациенты, лечившиеся с применением целлекса, характеризовались менее выраженным неврологическим дефицитом, большей мобильностью и лучшим глобальным когнитивным статусом при выписке по сравнению с группой контроля.