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Timely evaluation of cardioembolic stroke (CES) caused by atrial fibrillation is critical from the point of view of the possibility of prescribing effective secondary prevention with oral anticoagulants. Insular lesion is considered as a promising neuroimaging marker of CES.Objective: to analyze the role of insular cortex lesions using magnetic resonance imaging (MRI) of the brain as a potential neuroimaging marker of the pathogenetic subtype of ischemic stroke (IS).Patients and methods. 225 patients in the acute period of IS were examined. Depending on the stroke etiology, patients were divided into three groups: cryptogenic stroke (CS; n=99), CES (n=45), and non-CES (n=81). All patients underwent an MRI of the brain to analyze the insular cortex lesions. In 57 patients, foci of cerebral infarction were additionally marked manually on axial slices of diffusion-weighted MRI using the Anatomist software. The calculated MRI characteristics of foci for CES and non-CES groups were used to construct a decision tree in the WEKA 3.6 package. Echocardiographic markers of atrial cardiopathy were assessed in all patients – the left atrium (LA) emptying fraction and LA function index; in 68 patients, the concentration of serum NT-proBNP was also assessed.Results and discussion. The insula was affected in 12% of patients: most often in CES (33%), significantly less often in CS and non-CES (6 and 7.4%, respectively), without significant differences between the latter groups. The presence of insula lesion in relation to CES has a sensitivity of 33% and a specificity of 93% (p=0.002); odds ratio 6.25; 95% confidence interval 2.22–17.63. In most patients, the posterior insular cortex was involved in the pathological process. Isolated insular infarction occurred in only one patient with CES, while the involvement of the insula and adjacent zone, and the combination of insular infarction with territorial infarction, were observed more often. The group of patients with insular lesions was distinguished by the predominance of women, greater severity of stroke at admission, less deficit at discharge, larger LA diameter, lower LA emptying fraction, and functional index. CES was four times more common in the insular lesion group, while CS was two times more common in those without insular lesions. Insula involvement identifies three out of five CES patients according to the decision tree. Further analysis of the total lesion volume can locate almost all remaining patients with CES: they are characterized by the indicator >12 sm3.Conclusion. Insular lesions allow reliable differentiation of patients with CES and non-CES and can be considered a potential marker of the cardioembolic subtype of IS, which requires further investigation.
Timely evaluation of cardioembolic stroke (CES) caused by atrial fibrillation is critical from the point of view of the possibility of prescribing effective secondary prevention with oral anticoagulants. Insular lesion is considered as a promising neuroimaging marker of CES.Objective: to analyze the role of insular cortex lesions using magnetic resonance imaging (MRI) of the brain as a potential neuroimaging marker of the pathogenetic subtype of ischemic stroke (IS).Patients and methods. 225 patients in the acute period of IS were examined. Depending on the stroke etiology, patients were divided into three groups: cryptogenic stroke (CS; n=99), CES (n=45), and non-CES (n=81). All patients underwent an MRI of the brain to analyze the insular cortex lesions. In 57 patients, foci of cerebral infarction were additionally marked manually on axial slices of diffusion-weighted MRI using the Anatomist software. The calculated MRI characteristics of foci for CES and non-CES groups were used to construct a decision tree in the WEKA 3.6 package. Echocardiographic markers of atrial cardiopathy were assessed in all patients – the left atrium (LA) emptying fraction and LA function index; in 68 patients, the concentration of serum NT-proBNP was also assessed.Results and discussion. The insula was affected in 12% of patients: most often in CES (33%), significantly less often in CS and non-CES (6 and 7.4%, respectively), without significant differences between the latter groups. The presence of insula lesion in relation to CES has a sensitivity of 33% and a specificity of 93% (p=0.002); odds ratio 6.25; 95% confidence interval 2.22–17.63. In most patients, the posterior insular cortex was involved in the pathological process. Isolated insular infarction occurred in only one patient with CES, while the involvement of the insula and adjacent zone, and the combination of insular infarction with territorial infarction, were observed more often. The group of patients with insular lesions was distinguished by the predominance of women, greater severity of stroke at admission, less deficit at discharge, larger LA diameter, lower LA emptying fraction, and functional index. CES was four times more common in the insular lesion group, while CS was two times more common in those without insular lesions. Insula involvement identifies three out of five CES patients according to the decision tree. Further analysis of the total lesion volume can locate almost all remaining patients with CES: they are characterized by the indicator >12 sm3.Conclusion. Insular lesions allow reliable differentiation of patients with CES and non-CES and can be considered a potential marker of the cardioembolic subtype of IS, which requires further investigation.
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
Latent atrial fibrillation (AF), whose substrate is atrial cardiomyopathy (AC), is considered the main potential pathogenetic mechanism of cryptogenic embolic stroke (CES). Early detection of AC allows to intensify the search for AF in such patients.Objective: to compare the characteristics of patients with CES in terms of clinical and anamnestic data, echocardiographic parameters, MRI patterns of infarction foci and disease outcomes depending on the presence of the major markers for AC.Material and methods. We studied 103 patients in the acute phase of CES with a lesion confirmed by MRI data, who were divided into two groups according to the presence (n=17) or absence (n=86) of AC. A comprehensive clinical, laboratory, and instrumental examination was performed and long-term outcomes were assessed. The median follow-up period was 32 months.Results. The incidence of AC in the CES population was 17%; the most common markers were an increase in left atrial volume index and paroxysms of supraventricular tachycardia. Patients with AC-CES were characterised by older age and a two-fold increase in the prevalence of coronary heart disease. Patients with AC-CES were nine times more likely to have a "black artery" symptom on MRI than patients without AC. The predictive accuracy of this clinical pattern was 84%, the sensitivity was 60% and the specificity was 86%. Patients with AC-CES had a significantly higher risk (odds ratio 3.4; 95% confidence interval 1.1–9.9; p=0.023) for a composite outcome that included the development of recurrent ischemic stroke, transient ischemic attack, myocardial infarction or death.Conclusion. AC diagnosed by a combination of echocardiographic and electrocardiographic signs is present in 17% of patients with CES. Patients with AC-CES are characterised by elderly age, the presence of atherosclerosis-associated disease, a specific MRI pattern (the “black artery” symptom) and an unfavourable prognosis during the 2.5-year follow-up period.
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