Difficult issues in the management of patients with atrial fibrillation: a neurologist's point of view

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Своевременное определение патогенетического подтипа инсульта и раннее назначение таргетной вторичной профилактики является одним из императивов ведения пациентов с острым ишемическим инсультом (ИИ) [1]. В последние годы достигнуты существенные успехи в лечении пациентов с кардиоэмболическим инсультом (КЭИ), которые, в первую очередь, связаны с применением тромбэктомии [2], а также с более ранним назначением оральных антикоагулянтов (ОАК) [3]. Однако на повестке остается ряд важных проблем, в числе которых повышение эффективности поиска фибрилляции предсер-дий (ФП) у пациентов с эмболическим ИИ, решение вопроса о целесообразности ультрараннего (в первые 4 сут) назначения ОАК большинству пациентов, индивидуализация и повышение приверженности при их использовании. Обсуждению данных спорных позиций и посвящена настоящая статья.К л и н и ч е с к и е о с о б е н н о с т и К Э И КЭИ на фоне ФП занимает 13-26% в этиологической структуре ИИ. При этом его представленность выше у пациентов пожилого и старческого возраста [4]. Формирование

Issues of improving the management of patients with ischemic stroke on the background of atrial fibrillation

Кулеш

Demin

2022

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Patient with non-cardioembolic ischemic stroke or high-risk transient ischemic attack. Part 1. Diagnosis

Кулеш

Yanishevskiy

Demin

et al. 2023

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Non-cardioembolic stroke and transient ischemic attack (TIA) are heterogeneous conditions, some variants of which are associated with a high short-term and long-term risk of cardiovascular events. The article presents clinical portraits of patients in high and very high risk groups: 1) patients with extracranial atherosclerosis and severe stenosis/subocclusion/occlusion or CT signs of atherosclerotic plaque instability; 2) all patients with intracranial atherosclerosis, especially those with symptoms of hemodynamic compromise or multiple infarcts; 3) all patients with mobile/ulcerative atheroma of the aortic arch. For the timely identification of these subtypes, it is necessary to use clinical and radiological clues with necessary diagnostic search. In addition, the following patients with TIA may be at high or very high risk: those with an ABCD2 score of ≥4 points or an ABCD3-I score of ≥8 points; with TIA in the vertebrobasilar basin, "crescendo" or "limb shaking" type, orthostatic TIA, as well as patients with warning capsular and bridge syndromes. Assigning a patient to one of the considered categories requires the immediate administration of enhanced secondary prevention, which will be discussed in the second part of this article.

Transient ischemic attack in the vertebrobasilar vascular territory as a cause of isolated vertigo

Kulesh

2024

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Transient ischemic attack (TIA) in the vertebrobasilar vascular territory (VB) causes difficulties in diagnosis when it manifests only with vestibular symptoms. Issues relating to the differential diagnosis of TIA are discussed, awareness of which is necessary for the selection of informative methods of examination and the prescription of effective stroke prevention in patients with an episode of isolated dizziness. The likelihood of TIA as the cause of dizziness is increased by the patients' high cardiovascular risk, the presence of atrial fibrillation, severe instability during an attack, and head and/or neck pain. If a TIA in VB is suspected, it is advisable to perform a minimal instrumental examination, including computed tomography (CT) of the brain and CT angiography or diffusion-weighted magnetic resonance imaging (MRI) and MRI angiography. In case of doubt, additional information can be obtained by a perfusion CT or MRI as well as a post-contrast MRI. When interpreting the results of these methods of examination, their limitations in terms of application time and resolution should be taken into account.