Диференційні підходи до діагностики різних патогенетичних варіантів ішемічних інсультів у гострий період

Abstract

У статті розглядаються клінічні, інструментальні, лабораторні та патоморфологічні особливості різних патогенетичних підтипів ішемічного інсульту. Проведена диференційна діагностика між ними. Визначення підтипу ішемічного інсульту є надзвичайно актуальним питанням, оскільки впливає на вибір методів лікування та засобів вторинної профілактики. Було проаналізовано 20 летальних випадків ішемічного інсульту. Найчастіше зустрічався атеротромботичний варіант (55%). На долю кардіоемболічного інсульту припадає 35%. Диференційна діагностика різних патогенетичних варіантів основана на наявності чи відсутності атеросклеротичного ураження судин, кардіальної патології, артеріальної гіпотензії; В статье рассматриваются клинические, инструментальные, лабораторные и патоморфологические особенности различных патогенетических подтипов ишемического инсульта. Проведеная дифференциальная диагностика между ними. Определение подтипа ишемического инсульта является чрезвычайно актуальным вопросом, поскольку влияет на выбор методов лечения и средств вторичной профилактики. Было проанализировано 20 летальных случаев ишемического инсульта. Чаще встречался атеротромботический вариант (55%). На долю кардиоэмболического инсульта приходит 35%. Дифференциальная диагностика различных патогенетических вариантов основана на наличии или отсутствии атеросклеротического поражения сосудов, кардиальной патологии, артериальной ги- потензии; Introduction. At present stroke is an important public health concern worldwide as well as in Ukraine. Stroke is the third leading cause of death following heart diseases and cancer. For the last decade the incidence rate of cerebral diseases has grown twice. Objective. The research was aimed to find out the peculiarities of the acute period of ischemic stroke according to the pathogenetic mechanism of its development and make differential diagnosis of various pathogenic variants based on the analysis of clinical research data obtained by laboratory and instrumental examinations. Materials and methods. 20 lethal cases of ischemic stroke were analyzed. All patients were treated in the neurological department of the first Poltava municipal hospital. Clinical subtypes of ischemic stroke were assessed retrospectively. The study was conducted at the Poltava Regional Postmortem Office. We analyzed the findings obtained by examining clinical and neurological status of the patients, by studying cerebral matter with the laboratory, instrumental and macroscopic techniques. Much attention was paid to detecting any comorbidities. Results and discussion. An age of patients ranged from 64 to 84, the average age was 73 ± 1,2. The cases of males dominated and made up 90 % (18 cases). 60 % of the patients were hospitalized within 3-6 hours since the onset of serious condition had been npticed. The largest number of patients (80%) died within the first 3 days due to increased brain edema. 90% of patients suffered from hypertension. In 40% of cases in the centers was available secondary hemorrhage. 10% of the patients were observed to have hypotension, which could lead to hemodynamic mechanism of stroke. The patients deteriorated suddenly with the appearance of acute focal symptoms, which indicated the involvement of 2 pools in the pathological process, manifested in the form of motor aphasia, hemiplegia, bulbar disorders. 1 patient was revealed to have hypochromic anemia. We paid attention to the pathomorphological features of hemodynamic stroke subtype: - The presence of atherosclerosis in fine and main arteries; - The stoke foci were extensive up to 6 cm in diameter; - The absence of left ventricular hypertrophy; - The absence of thromboembolism (the patients did not take anticoagulants that enabled to exclude heparyn resorption"). At the time of hospitalization 7 (35%) patients were detected to have some changes of heart rate. The development of the disease in these patients testified the type of cardioembolic stroke. Pathological features of this type were the following: - The presence of diffuse myocardial changes (usually postinfarction), left ventricular hypertrophy; - Not marked atherosclerosis of fine and main arteries; - Large infarction sites in the cerebral hemispheres (diameter 6 - 12 cm). 11 (55%) patients were established to have atherothrombotic mechanism of acute cerebrovascular accident. The patients were overweight (over 90 kg). During postmortem study we revealed: - Pronounced cerebral atherosclerosis of vessels in brain, aorta, heart, kidney (vascular color was yellowish); - Vasoconstriction of atherosclerotic lesions; - Absence of cardiac pathology that could lead to embolism. Conclusions. The findings obtained by clinical, neuroimaging, laboratory, postmortem studies have found out the peculiarities of the acute period of ischemic strokes depending on the pathogenetic mechanism of their development. We have distinguished the basic subtypes of stroke in acute period as well as have established the correlation between different pathogenic variants (10% of haemodynamic variant, 35% of cardioembolic variant, and 55% of atherothrombotic variant). Differential diagnosis of various pathogenic variants is based on the presence or absence of atherosclerotic vascular lesions, cardiac disease, hypotension.