Background: In patients with atrial fibrillation who suffered an ischemic stroke while on treatment with nonvitamin K antagonist oral anticoagulants, rates and determinants of recurrent ischemic events and major bleedings remain uncertain. Methods: This prospective multicenter observational study aimed to estimate the rates of ischemic and bleeding events and their determinants in the follow-up of consecutive patients with atrial fibrillation who suffered an acute cerebrovascular ischemic event while on nonvitamin K antagonist oral anticoagulant treatment. Afterwards, we compared the estimated risks of ischemic and bleeding events between the patients in whom anticoagulant therapy was changed to those who continued the original treatment. Results: After a mean follow-up time of 15.0±10.9 months, 192 out of 1240 patients (15.5%) had 207 ischemic or bleeding events corresponding to an annual rate of 13.4%. Among the events, 111 were ischemic strokes, 15 systemic embolisms, 24 intracranial bleedings, and 57 major extracranial bleedings. Predictive factors of recurrent ischemic events (strokes and systemic embolisms) included CHA 2 DS 2 -VASc score after the index event (odds ratio [OR], 1.2 [95% CI, 1.0–1.3] for each point increase; P =0.05) and hypertension (OR, 2.3 [95% CI, 1.0–5.1]; P =0.04). Predictive factors of bleeding events (intracranial and major extracranial bleedings) included age (OR, 1.1 [95% CI, 1.0–1.2] for each year increase; P =0.002), history of major bleeding (OR, 6.9 [95% CI, 3.4–14.2]; P =0.0001) and the concomitant administration of an antiplatelet agent (OR, 2.8 [95% CI, 1.4–5.5]; P =0.003). Rates of ischemic and bleeding events were no different in patients who changed or not changed the original nonvitamin K antagonist oral anticoagulants treatment (OR, 1.2 [95% CI, 0.8–1.7]). Conclusions: Patients suffering a stroke despite being on nonvitamin K antagonist oral anticoagulant therapy are at high risk of recurrent ischemic stroke and bleeding. In these patients, further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischemic stroke and bleeding.

Cerebral stroke remains the leading cause of death and disability worldwide as well as in Ukraine. After a cerebral stroke, there is an increased risk of a new cerebral stroke (9‒15 % within 1 year), and about a quarter of all cerebral stroke are recurrent. Up to 80 % of recurrent cerebral stroke can be avoided through lifestyle modifications (healthy diet, sufficient amount of physical activity, normalization of body weight, cessation of smoking and alcohol abuse) and control of chronic diseases such as hypertension, diabetes, hyperlipidemia and atrial fibrillation. The key to effective secondary prevention is determining the etiology of cerebral stroke, which requires a primary examination in all cases and a number of additional tests as needed. The most common causes of ischemic cerebral stroke are cardiogenic embolism, atherosclerosis of the large cerebral arteries (macroangiopathy), and brain small vessels disease (microangiopathy), but approximately 1/3 of cerebral stroke have other, rear, determined cause or the cause remains unknown despite the appropriate workup (cryptogenic cerebral stroke). In the review, we discuss modern approaches to ischemic cerebral stroke classification and determination of their etiology, from the most prevalent to the rarest causes. A careful search for the cause of cerebral stroke is particularly important in young patients (aged 18 to 50 years) with a high life expectancy. We have reviewed in detail the possibilities of screening for subclinical atrial fibrillation by long-term cardiac monitoring with implantable devices and the diagnosis of monogenetic causes of cerebral stroke, with a particular focus on Fabry disease, for which there is an effective treatment.

Цель — оценка частоты и степени тяжести почечной дисфункции у пациентов с мозговым инсультом (МИ) и определение предикторов умеренного или тяжелого снижения расчетной скорости клубочковой фильтрации (рСКФ). Материалы и методы. Проведен анализ данных 360 пациентов с верифицированным диагнозом МИ, которые в 2010–2018 гг. были госпитализированы в разные периоды МИ. У всех участников при поступлении на автоматическом анализаторе DiaSys respons® 920 был определен уровень креатинина в крови, а затем по формуле CKD-EPI определена рСКФ. Показатели рСКФ от 89 до 60 мл/мин/1,73 м2 считали легким, а < 60 мл/мин/1,73 м2 — умеренным или тяжелым снижением рСКФ. Качественные переменные отражены как число и проценты, количественные переменные — с помощью медианы и межквартильного интервала (МКИ). Анализ данных проводился с использованием пакета MedCalc® Statistical Software. Результаты. В выборке женщины составили 41,7 %, медиана возраста составила 66 лет (МКИ 58–75), у 301 (83,6 %) пациента диагностирован ишемический инсульт (ИИ), медиана исходной оценки по NIHSS — 10 баллов (МКИ 6–17). У участников документирована высокая частота основных сосудистых факторов риска: 82,2 % страдали артериальной гипертензией (АГ), 36,4 % — фибрилляцией предсердий, 28,6 % — сахарным диабетом, 30,6 % — ожирением, 14,7 % были курильщиками, 16,4 % злоупотребляли алкоголем, а у 23,3 % МИ был повторным. Показатели рСКФ варьировали от 11,1 до 174,7 мл/мин/1,73 м2 (медиана 87,8, МКИ 62,5–98,5). У 55,0 % пациентов рСКФ была снижена, в частности у 32,2 % наблюдалось легкое, а у 22,8 % — умеренное или тяжелое снижение рСКФ. Значимых различий по рСКФ при различных типах МИ не обнаружено, но снижение рСКФ чаще наблюдалось при кардиоэмболическом ИИ по сравнению с атеротромботическим ИИ: 63,2 и 47,9 % соответственно (p < 0,05). Согласно результатам многофакторного анализа, независимыми предикторами умеренного или тяжелого снижения рСКФ оказались возраст пациента (отношение шансов (ОШ) 1,02; 95% доверительный интервал (ДИ) 1,00–1,05, в среднем на каждый дополнительный год, р = 0,044), мужской пол (ОШ 5,2; 95% ДИ 2,7–9,9; р < 0,001) и наличие в анамнезе АГ (ОШ 2,7; 95% ДИ 1,2–6,4; р = 0,022). Модель, построенная на основе трех выделенных факторов, оказалась адекватной, но площадь под кривой AUC = 0,70 (95% ДИ 0,65–0,75) свидетельствует об умеренной связи. Выводы. Ренальную дисфункцию имеют больше половины пациентов с МИ, и почти в 1/4 случаев наблюдается умеренное или тяжелое снижение рСКФ (хроническая болезнь почек 3–5-й стадий). Поскольку АГ является предиктором умеренной или тяжелой ренальной дисфункции у пациентов с МИ, лучший контроль АГ (прежде всего с помощью ингибиторов ренин-ангиотензиновой системы) может быть действенным способом профилактики тяжелой хронической болезни почек.

Objective – to explore the possibility of integral assessment of the stroke outcome and to develop a method of integral assessment of the stroke outcome after in-patient treatment on the level of impairment and and the level of activities of daily living, which were assessed using rating scales and indices.Materials and methods. The study was conducted at the Stroke Center (SC), Oberig’ multidisciplinary hospital division, which operates according to the principles of Comprehensive Stroke Unit. Patients with a cerebral stroke who were admitted to the SC in 2010–2018 were enrolled. The data of the participants were prospectively entered into a special database and included discharge assessments using 8 valid rating scales and indices. Cluster analysis methods (in particular Kohonen neural networks) were used to design the integral assessment. Statistical analysis of the values ​​of the rating scales and indices in the selected clusters was performed using the Kruskal–Wallis criterion, post hoc comparisons were made using the Dunn multiple comparison criterion.Results. 852 patients (42.5 % women and 57.5 % men, median age – 66.7 year) were enrolled. 81 % of patients were diagnosed with ischemic stroke, and 19 % had hemorrhagic stroke. According to the chosen method, it is necessary and sufficient to split the data into 4 clusters. All participants in the study according to their assessments at discharge using the set of selected measures could be assigned to one of 4 isolated clusters: K1 (n = 366), K2 (n = 93), K3 (n = 104) or K4 (n = 289). National Institutes of Health Stroke Scale, modified Rankin scale, Barthel Index, Berg Balance Scale та Functional Ambulation Classification were the most significant determinants of the patient cluster. For the 5 measures there have been significant differences (p < 0.001) in the four clusters. The condition of the patients in K4 cluster was the best (p < 0.05), whereas the patients in the K1 cluster were worse (p < 0.05), and the condition of the patients in the clusters K2 and K3 was much worse (p < 0.05) compared with the cluster K4.Conclusions. Based on the integrated assessments of neurological impairments and activities of daily living all of stroke patients could be assigned to one of four identified clusters. Detecting predictors of poor outcome after in-patient management may help to find ways to improve their prognosis.

Introduction: Ischaemic stroke patients with atrial fibrillation (AF) are at high risk of stroke recurrence despite oral anticoagulation therapy. Patients with cardiovascular comorbidities may take both antiplatelet and oral anticoagulation therapy (OAC/AP). Our study aims to evaluate the safety and efficacy of OAC/AP therapy as secondary prevention in people with AF and ischaemic stroke. Patients and methods: We performed a post-hoc analysis of pooled individual data from multicenter prospective cohort studies and compared outcomes in the OAC/AP cohort and patients on DOAC/VKA anticoagulation alone (OAC cohort). Primary outcome was a composite of ischaemic stroke, systemic embolism, intracranial bleeding, and major extracranial bleeding, while secondary outcomes were ischaemic and haemorrhagic events considered separately. A multivariable logistic regression analysis was performed to identify independent predictors for outcome events. To compare the risk of outcome events between the two cohorts, the relation between the survival function and the set of explanatory variables were calculated by Cox proportional hazard models and the results were reported as adjusted hazard ratios (HR). Finally another analysis was performed to compare the overall risk of outcome events in both OAC/AP and OAC cohorts after propensity score matching (PSM). Results: During a mean follow-up time of 7.5 ± 9.1 months (median follow-up time 3.5 months, interquartile range ±3), 2284 stroke patients were on oral anticoagulants and 215 were on combined therapy. The multivariable model demonstrated that the composite outcome is associated with age (OR: 1.03, 95% CI: 1.01–1.04 for each year increase) and concomitant antiplatelet therapy (OR: 2.2, 95% CI: 1.48–3.27), the ischaemic outcome with congestive heart failure (OR: 1.55, 95% CI: 1.02–2.36) and concomitant antiplatelet therapy (OR: 1.93, 95% CI: 1.19–3.13) and the haemorrhagic outcome with age (OR: 1.03, 95% CI: 1.01–1.06 for each year increase), alcoholism (OR: 2.15, 95% CI: 1.06–4.39) and concomitant antiplatelet therapy (OR: 2.22, 95% CI: 1.23–4.02). Cox regression demonstrated a higher rate of the composite outcome (hazard ratio of 1.93 [95% CI, 1.35–2.76]), ischaemic events (HR: 2.05 [95% CI: 1.45–2.87]) and bleeding outcomes (HR: 1.90 [95% CI, 1.06–3.40]) in OAC/AP cohort. After PSM analysis, the composite outcome remained more frequent in people treated with OAC + AP (RR: 1.70 [95% CI, 1.05–2.74]). Discussion: Secondary prevention with combination of oral anticoagulant and antiplatelet therapy after ischaemic stroke was associated with worse outcomes in our cohort. Conclusion: Further research is needed to improve secondary prevention by investigating the mechanisms of recurrent ischaemic stroke in patients with atrial fibrillation.

Objective ‒ to implement a inified algorithm for determining an ischemic cerebral stroke (ICS) etiological subtype and evaluate the results of its use in patients who were admitted to a comprehensive stroke unit (CSU).Materials and methods. The study enrolled 689 patients with ICS (43.4 % women, 56.6 % men; median age 68.1 years (59.7–75.5)) who in 2010 to 2018 were admitted to a hospital unit where the structure and processes correspond to the principles of CSU. The participants’ age, gender, National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale scores were analyzed. All patients underwent an initial workup that included neuroimaging, vascular imaging, a cardiologist’s exam and a set of laboratory tests, and an advanced evaluation, at his physician discretion. All ICS was assigned to one of the four etiological subtypes: cardioembolic, atherosclerotic, lacunar or other. Results. According to the proposed algorithm, 294 (42.7 %) cases were assigned to cardioembolic subtype, 282 (40.9 %) to atherosclerotic subtype, 52 (7.5 %) to lacunar subtype and 61 (8.9 %) to ischemic cerebral stroke unknown etiology. Differences in the shown frequency of the main etiological ICS subtypes compared to the results of epidemiological studies are due to the greater severity of ICS in our sample: baseline median NIHSS total score was 10 (6–17), and median modified Rankin scale score was 4 (3–5), and, on the other hand, to in-depth assessment using modern diagnostic technologies and a longer length of stay that allowed for the tests to be completed.Conclusions. Thorough evaluation and the use of a unified algorithm based on causal etiological classifications allow to successfully determine an ICS subtype in the CSU patients with low proportion of ICS of unknown etiology, which is the key to effective secondary prevention.

Цель. Обобщение данных литературы и собственного опыта выполнения чрескожной эндоскопической гастростомии (ЧЭГ). Материалы и методы. За период с 2011 по 2018 г. 105 пациентам клиники «Обериг» выполнена ЧЭГ. Проанализированы результаты, показания, противопоказания, методика установки гастростомы, особенности лечения пациентов, осложнения. Результаты. Выполнение ЧЭГ было технически успешным во всех наблюдениях. Всего отмечено 5 (4,8%) осложнений (95% доверительный интервал (ДИ) 1,6 - 10,8): несостоятельность гастростомы с перитонитом (1), пневмоперитонеум (1), кровотечение из брюшной стенки (1), инфильтрат мягких тканей передней брюшной стенки (1), миграция бампера гастростомы в стенку желудка (1). В сроки наблюдения 30 дней летальности не было. Выводы. ЧЭГ – безопасный, доступный миниинвазивный метод, который является выбором у пациентов, требующих длительного энтерального питания или длительной декомпрессии желудка. Необходимы строгое соблюдение всех технических этапов ЧЭГ, показаний и противопоказаний, правильный послеоперационный уход за стомой.

Инсульт остается ведущей причиной смертности и приобретенной инвалидности среди людей старшего возраста во всем мире. К числу факторов, оказывающих наибольшее влияние на результаты лечения инсульта в стационаре, относятся клинико-демографические особенности больного, ресурсы больницы и организация лечебного процесса в отделении, где находится пациент. При остром инсульте качественная медицинская помощь способствует снижению риска смерти и зависимости от посторонней помощи. Хотя оптимальная модель организации помощи в стационаре пока не определена, накоплен большой объем доказательств эффективности инсультного блока (Stroke Unit), где структура и процессы имеют существенные особенности по сравнению с общей палатой. Наибольшие преимущества при лечении инсульта в стационаре обеспечивают комплексные инсультные блоки, позволяющие сочетать решение острых медицинских проблем и интенсивную междисциплинарную реабилитацию. Деятельность инсультного центра клиники «Оберіг» подтверждает возможность создания в Украине комплексного инсультного блока и достижения лучших результатов лечения инсульта в стационаре.