Таксономическая характеристика бактериальной ДНК, выделенной из тромбов пациентов с ишемическим инсультом

Section Editors: Marc Fisher MD Antoni Davalos MD The Food and Drug Administration (FDA) evaluates applications for new human drugs, biologics, and complex medical devices. Companies must obtain FDA approval to legally market these products. In August, the FDA gave Concentric Medical clearance to market its Merci Retriever system to “remove blood clots from the brain in patients experiencing an ischemic stroke.” Given that the FDA is charged with “protecting the public health by assuring the safety, efficacy, and security of… biological products and medical devices…, ” “advancing public health by helping to speed innovations that make medicines … more effective, safer, and more affordable,” and “helping the public get the accurate, science-based information they need to use medicines … to improve their health,”1 the FDA’s decision to approve the Merci Retriever system is of concern. The pathways to approval are reviewed by Felten et al in the accompanying article and are outlined in Figure 1. Figure 1. Potential pathways for device approval. The decision to approve the Merci Retriever was based on data from the MERCI (Mechanical Embolus Removal in Cerebral Ischemia) Trial; the approval was granted through the 510(k) process. The Merci Retriever system includes a flexible nickel titanium (nitinol) wire that obtains a helical shape once it is passed through the tip of the guidance catheter. In practice, the catheter/wire is passed distal to the thrombus, the catheter is removed, and the helical configuration assumed by the wire; the clot is then trapped in the helix and withdrawn from the vasculature (Figure 2). The 510(k) clearance means that the Merci Retriever was felt to be substantially equivalent to a predicate device. In this case, the predicate device was the Concentric Retriever, which itself received 510(k) clearance by the FDA in May 2001 for “use in …

Introduction. Acute disorders of cerebral circulation - strokes - are the most important medical and social problem, due to their high proportion in the structure of morbidity and mortality of the population, signifi cant indicators of temporary labor losses and primary disability. In this regard, one of the main tasks of Russian healthcare is to slow down the increase in the disability of the population, which is carried out through the active development of the rehabilitation system in our country, including neurorehabilitation. Osteopathic correction can become one of the new areas of rehabilitation for this group of patients. There have already been made previous attempts to study the osteopathic status in patients with acute cerebrovascular accident and to assess the possible contribution of somatic dysfunctions to the pathogenesis of this disease. At the same time, there are no publications in the available scientifi c literature about the possibility of osteopathic correction using in the rehabilitation of patients with acute cerebrovascular accident in the early recovery period. All of the above predetermined the purpose of the study.The aim of the study is to substantiate the possibility of osteopathic correction methods using in the complex rehabilitation of patients with acute cerebrovascular accident in the early recovery period.Materials and methods. A prospective randomized controlled study was conducted from February 2019 to March 2020 on the basis of the neurorehabilitation department of the State Clinical Hospital № 11 (Omsk). 40 patients with a diagnosis of acute cerebrovascular accident, early recovery period were under observation. The sample was entire. Patients, depending on the method of used treatment, were divided with using the method of simple randomization into two comparable groups of 20 people: main and control. All patients received complex rehabilitation treatment, which included drug therapy, physiotherapy, kinesiotherapy, massage, and acupuncture. Additionally, patients of the main group received osteopathic correction (3 sessions). All patients, regardless of the group, before the start, as well as after the completion of the rehabilitation course, were assessed for osteopathic status, the level of self-care, daily activity and mobility of patients was determined using functional scales, and muscle strength of the hands was studied using dynamometry.Results. Patients with ischemic stroke in the early recovery period are characterized by the presence of somatic dysfunctions, mainly at the global and regional levels. 100 % of the examined participants had a global rhythmogenic cranial disorder. The most characteristic regional somatic dysfunctions were of the neck region, the structural component (29 %), and of the dura mater region (24 %). After completion of rehabilitation, global rhythmogenic cranial somatic dysfunction remained in all patients (100 %), however, in the group that received osteopathic correction, its severity was statistically signifi cantly reduced (p<0,05). Also, in the main group, the average number of regional somatic dysfunctions and their severity changed statistically more signifi cantly (p<0,05). At the background of complex rehabilitation treatment, all patients had an increase in the level of self-care, daily and physical activity according to neurorehabilitation scales, and also increased arm muscle strength according to dynamometry. However, in the group receiving additional osteopathic correction, these indicators were statistically signifi cantly higher (p<0,05).Conclusion. Rehabilitation of patients with vascular pathology, including those with ischemic stroke, is one of the most important directions in the development of the modern healthcare system. This dictates the need to search and study new methods and means of rehabilitation, one of which could be osteopathy. This study showed that the inclusion of osteopathic correction in the program of complex rehabilitation of patients with ischemic stroke in the early recovery period will achieve better results in terms of restoring lost functions and improving self-care skills. In order to introduce the new method more widely, it is advisable to continue the study on an even larger sample.

### Case A 68-year-old right-hand-dominant man was brought to the hospital because of a speech disturbance and right arm and leg weakness. He awoke with these deficits and was last known to be symptom-free when retiring to bed the previous evening 8 hours earlier. His past medical history was notable for coronary heart disease, the patient having underwent coronary artery bypass surgery 7 years previously for unstable angina, but he had no known history of myocardial infarction. He also had hypertension and hyperlipidemia, and smoked 1 pack of cigarettes daily for more than 40 years. He had no history of calf claudication. His hypertension was being treated with a diuretic and β-adrenergic receptor blocker. He was also prescribed 325 mg of aspirin daily and an HMG CoA-reductase inhibitor (statin); however, his wife remarked that he often forgot to take his medications. His last total cholesterol was 240 mg/dL, with LDL cholesterol of 130 mg/dL. He had a strong family history of coronary heart disease after the age of 50. He had no known drug allergies. #### Physical Examination The patient’s blood pressure was 195/100 mm Hg in both arms, with a regular pulse of 90 bpm. His weight was 225 lb (body mass index: 31.4 kg/m2). His lungs were clear to auscultation. Cardiac examination showed a laterally displaced point of maximum impulse with an S4 gallop and a soft nonradiating systolic murmur at the base. His abdomen was obese without organomegaly and no abdominal bruits were detected. He had no rashes and no joint deformities. The left superficial temporal artery pulse was stronger than the right. There were soft bilateral anterior cervical bruits, left louder than right, but no supraclavicular bruits. There were bilateral femoral bruits. Radial pulses were 2+ and symmetric. Dorsalis pedis and posterior tibial pulses were 1+. …

Marc Fisher MD Kennedy Lees MD Section Editors: Hypertension is the most important modifiable risk factor for stroke.1,2 It is estimated that 25% or more of strokes may be attributable to hypertension. Because many patients with stroke have mild hypertension or prehypertension, we have shifted our focus and now think of stroke on a continuum of risk based on blood pressure (BP) level rather than on a threshold effect.3 Because high BP may not exist in isolation, a wider definition of hypertension has been proposed that also takes into account the absolute risk of cardiovascular events and associated metabolic factors or early disease markers.3 Lowering BP reduces the risk of stroke. Epidemiological studies have shown that for each 10 mm Hg lower systolic blood pressure (SBP), there is a decrease in risk of stroke of approximately one third in persons aged 60 to 79 years. This association is continuous down to levels of at least 115/75 mm Hg and is consistent across sexes, regions, stroke subtypes, and for fatal and nonfatal events.4 Lowering diastolic blood pressure (DBP) was once the main target to achieve stroke and other cardiovascular event reduction, but SBP has now become the target.3 As recently shown, even the elderly with sustained SBP elevation may gain from BP reduction in relation to less fatal or nonfatal stroke, death, and heart failure.5 Although the role of longer-term BP control to improve outcomes in patients with stroke is undisputed, BP management immediately after a stroke remains controversial. In an effort to resolve this controversy, several pilot clinical trials have been initiated. In this review, we discuss the results of some of these trials and available evidence-based guidelines for BP control in the settings of acute ischemic and hemorrhagic stroke (excluding subarachnoid hemorrhage) and …

d’Esterre, CD1, 3 Qazi, E1, 3 Patil, S1, 3 Almekhlafi, M3, 1 Lee, T2, 3 Demchuk, A1, 3 Goyal, M1, 3 Menon, B1, 3; 1. University of Calgary, Calgary, AB; 2. University of Western Ontario, London, ON; 3. Calgary Stroke Program, Calgary, AB Background : For ischemic stroke, CT Perfusion (CTP) may change thrombolytic/endovascular treatment decisions when compared to NCCT/CTA alone. Two distinct thresholds may be useful in this regard: separation of 1) non-salvageable tissue (infarct core) from salvageable electrically silent tissue (penumbra), and 2) penumbra from benign oligemia (hypoperfused, but will survive if clot persists). Methods : CTP (120s,8cm) was performed on 180 patients within 12hrs of ischemic stroke. Two patient cohorts were analyzed: (1) recanalization (TICI 2b,3) 6s. For group (2) CBF, CBV, and Tmax values were obtained from within the final infarct region, and total ipsilateral hemisphere, excluding infarction. CBF, CBV and Tmax were used in univariate regression models. Results : For group (1)[n=11], mean time from CTP to recanalization was 60±19min. CBF parameter (thresholds for gray and white matter 7.2 and 5.2 ml•min-1•(100g)-1) had the highest sensitivity (90.9%) and specificity (81.8%) for infarction. For group (2)[n=15], the Tmax parameter (thresholds for gray and white matter 11.3s and 11.8s) had the highest sensitivity (86.6%) and specificity (80.0%) for penumbra. Conclusion : Knowing the status of recanalization within 90mins of CTP allows for accurate delineation of infarct core, as …

See related article, pages 1826–1830. The goal of acute stroke evaluation is to determine not only stroke type (ischemic versus hemorrhagic) and localization (anatomical and vascular), but perhaps more importantly, to determine reversibility (presence of an ischemic penumbra that may be salvaged with acute therapy). Traditionally, neurologists have relied on history and neurological examination to provide much of this information. However, long experience has demonstrated that the neurological examination is imperfect at best in determining lesion localization and grossly limited in its ability to provide insights into the presence of penumbral tissue. This is evidenced by the only modest correlations between National Institutes of Health Stroke Scale (NIHSS) score and perfusion-weighted imaging lesion volume.1,2 The last decade has seen a striking growth in neuroimaging techniques that provide important real-time information about acute stroke pathophysiology. In the mid-1990s the advent of diffusion-weighted imaging revolutionized the role of MRI in acute stroke evaluation. Not …

A multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke caused by proximal arterial occlusion in the anterior circulation.

Clinical management of patients with acute stroke and the approach used for secondary prevention depends upon clarification of pathogenesis. Although most strokes are a consequence of cerebrovascular disease, ≈15% to 20% of ischemic (nonhemorrhagic) strokes have been attributed to cardiogenic embolism.1 In practice, determination of the stroke mechanism is fraught with uncertainty, particularly when the possibility of thromboembolism emanating from atherosclerotic lesions in the aorta or cervical arteries is considered. When cardiogenic embolism is suspected, cardiac ultrasound is the principal method used to identify the potential source. The finding of left atrial enlargement has been shown to bear a significant relationship to the risk of stroke in a multivariate analysis of population-based data from the Framingham Heart Study2. The most frequent confounding variable is atrial fibrillation, occurring in >2 million patients in North America and in over half of all patients with cardiogenic embolism. Criteria for selection of patients with acute ischemic stroke for transesophageal echocardiography (TEE) to search for a potential cardiac source of embolism are controversial, particularly because cardiogenic embolism is often an uncertain diagnosis that is inferred merely on the basis of the finding of potential cardiac source. Even after extensive investigation, ≈40% of ischemic stroke patients have no clearly identifiable pathogenesis (cryptogenic stroke).3 In one study, 62% of patients younger than 60 years of age without an obvious source of cerebral infarction and 23% of those with arterial lesions had potential sources of cardiogenic embolism identified by TEE ( P =0.0007 for the difference).4 See p 2625 Among the cardiac anomalies detected by TEE that have been implicated as risk factors for stroke are patent foramen ovale (PFO) and atrial septal aneurysm (ASA).5,6⇓ The foramen ovale, a remnant of the fetal circulation, remains patent through adulthood in ≈1 in 4 …

Evaluating Age, Sex, Racial, and Ethnic Representation in Acute Ischemic Stroke Trials, 2010 to 2020: A Systematic Review and Meta-Analysis.

Discharge ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes have been used to identify patients with acute stroke for epidemiological, quality of care, and cost studies. The aim of this study was to determine if the accuracy of the primary ICD-9-CM codes for ischemic stroke is improved by modifier codes and how specific codes reflect stroke subtype diagnoses. Available hospital charts for all patients discharged from a single hospital between May 1995 and June 1997 with ICD-9-CM codes 433 (occlusion and stenosis of precerebral arteries), 434 (occlusion of cerebral arteries), or 436 (acute but ill-defined cerebrovascular disease) listed in the first position were reviewed. The primary discharge diagnosis was verified, and a presumed stroke subtype was assigned on the basis of information provided in the medical record. Charts were available for 175 of the 198 identified patients (88%). Of these, 61% had an acute ischemic stroke (code 433, 4%; 434, 82%; 436, 79%) with the remaining patients having other conditions. Of the 130 patients with a modifier code indicating cerebral infarction, 79% had an acute stroke; of the 45 patients with a modifier code indicating an absence of cerebral infarction, 7% had acute stroke (sensitivity, 0.97; specificity, 0.60). The codes with the highest proportions of ischemic stroke cases were 434.11 (embolic occlusion of cerebral arteries with infarction, 85%), 434.91 (unspecified occlusion of precerebral arteries with infarction, 82%), and 436 (79%), with a combined sensitivity of 0.81 and specificity of 0.90. On review, 73% of patients with code 434.11 had embolic strokes, and 47% of those with code 436 had an identified stroke cause. Of patients with code 434.91, 39% had stroke of uncertain cause, 25% "lacunar," 17% atherothrombosis, and 15% embolism. Despite the use of modifier codes, 15% to 20% of patients with the indicated primary ICD-9-CM codes have conditions other than acute ischemic stroke. Although the proportion of patients with acute stroke increased from 61% to 79% with the use of modifier codes, the inclusion of modifier codes did not have an appreciable effect on the accuracy of the coding if patients with code 433 are excluded. Assignment of presumed ischemic stroke subtype is particularly inaccurate.

Objective To investigate whether routine laboratory findings should be awaited before intravenous thrombolytic therapy for ischemic stroke. Methods Emergency patients (including ischemic and non-ischemic stroke cases) treated at the Department of Neurology, Beijing Tsinghua Changgung Hospital between January 1st 2016 and October 1st 2017 were analyzed retrospectively. The platelet count, prothrombin time (PT), activated partial thromboplastin time (APTT), and international normalized ratio (INR) in the first test were used as the main indicators. The proportion of patients with abnormalities between the overall population and the ischemic stroke subgroup was analyzed, and the above indicators between all patients with ischemic stroke and those receiving intravenous thrombolytic therapy were compared. The specific causes of failure to receive intravenous thrombolytic therapy in patients with ischemic stroke were analyzed descriptively. Results A total of 3 348 patients were enrolled. The emergency blood routine data were available in all patients. The emergency blood biochemical data were available in 3 278 patients (97.9%), and the emergency coagulation function data were available 1 742 patients (52.0%). There were no significant differences in the proportion of platelet count 36.5 s (3.8% vs. 3.6%; χ2=0.06, P=0.809), PT >15 s (2.6% vs. 2.8%; χ2=0.03, P=0.866), and INR>1.5 (2.0% vs. 2.0%; χ2=0.01, P=0.970) between the general population and the ischemic stroke subgroup. In a total of 687 patients with ischemic stroke, 57 (8.3%) received intravenous thrombolysis. There were no significant difference in mean platelet count, APTT, PT, and INR between the thrombolytic group and the entire ischemic stroke group. Forty-nine patients (5.1%) with ischemic stroke had abnormal main indicators, of which 57.1% (28/49) had a history of related diseases at the same time, while only 6.1% (3/49) had abnormal laboratory indicators as the main factor of contraindication for intravenous thrombolysis. Conclusions Patients with acute ischemic stroke (especially in the absence of a history of related disease) have a low proportion of abnormal blood test findings and are less likely to be the main contributor of contraindication for intravenous thrombolysis. Therefore, when there is no reason to suspect that the test findings are abnormal, intravenous thrombolytic therapy should not be delayed because of waiting for the test findings. Key words: Stroke; Brain ischemia; Thrombolytic therapy; Infusions, intravenous; Point-of-care systems; Time factors

Background. Carotid endarterectomy is an effective and safe operation aimed at treating patients with hemo-dynamically significant stenosis of the carotid arteries, the outcomes of which are well studied, and the permissible levels of postoperative complications are presented in the current recommendations. Nevertheless, the issues related to the incidence of cardiovascular accidents in different age groups of patients have not been sufficiently studied. Objective. Analysis of hospital outcomes of carotid endarterectomy in different age groups. Design and methods. The study included 1416 patients who were operated on for stenotic lesions of the internal carotid arteries. According to the WHO classification, patients were divided into groups depending on age: up to 44 years — young age (n = 76); 45-59 years old — average age (n = 291); 60-74 — old age (n = 835); over 75 years old — old age (n = 214). The compensatory capabilities of cerebral blood flow were assessed by invasive measurement of the retrograde pressure in the internal carotid artery. The endpoints were death, myocardial infarction, acute cerebrovascular accident, transient ischemic attack, hemorrhagic complications, cranial nerve damage, combined endpoint. Results. There were no significant differences in the incidence of all cardiovascular events. In the group of young patients, no lethal outcomes, myocardial infarction, acute cerebrovascular accident, or transient ischemic attack were recorded. All deaths were caused by the development of ischemic stroke as a result of distal embolization. In cases of non-fatal acute disorders of cerebral circulation, transient ischemic attacks in 1 patient of the 60-74 year group, the catastrophe developed against the background of thrombosis of the internal carotid arteries. In other 3 cases, on the background of the development of hyperperfusion syndrome. In 1 patient of the 60-74 year group, hemorrhagic transformation of the old ischemic focus with the development of intracerebral hematoma was recorded. There was also no significant intergroup difference in the incidence of hemorrhagic complications. The total number of all cardiovascular events in each group and the sample as a whole did not exceed one and a half percent, which corresponded to the standards described in the current recommendations. Conclusion. There was no statistically significant difference in the development of adverse cardiovascular events depending on the patient’s age.

The widespread prevalence of acute cerebrovascular accidents (ACVA) around the world (up to 30 million annually), high disability draw close attention of doctors to the system of care for patients with strokes. Rehabilitation is of great importance in it, the main task of which is to restore impaired body functions and return patients to a full life. The best way to organize rehabilitation is considered to be an integrated approach with the formation of a multidisciplinary team of doctors. An individual approach to each patient is also important: his age, medical history, social status, relationships with family, lifestyle. Doctors carry out rehabilitation measures to restore the patient's motor, social, household and psychoemotional functions. The results of rehabilitation and restoration of health of people who have suffered a stroke depend on many factors, but to a large extent on a favorable attitude and the persistent desire of the patients themselves to return to health. The aim of the study was, based on the results of studying the case histories of patients with ischemic and hemorrhagic stroke of the neurological department on the basis of the BUZ UR of the First Republican Clinical Hospital of the Ministry of Health of the UR, to assess the effectiveness of rehabilitation of patients who underwent stroke.

Low rate of intracerebral hemorrhage after cardiac catheterization in patients with acute ischemic stroke in a large case series

Objective: To compare the frequency of post-stroke seizure between acute ischemic and haemorrhagic stroke patients. Study Design: Comparative, prospective study. Place and Duration of Study: Combined Military Hospital, Rawalpindi Pakistan, from Oct 2021 to Oct 2022. Methodology: A total of 180 patients with acute stroke, were included in the study. CT brain and/or MRI brain were performed to diagnose all patients. Patients were divided into haemorrhagic and ischemic stroke groups. Patients were followed for four weeks. Results: The mean age of the patients was 48.92±7.80 years. The majority were males 127(70.5%),125(69.4%) patients had an ischemic stroke, while 55(30.6%) had haemorrhagic. Post-stroke seizures were seen in 12(7.07%). In haemorrhagic stroke patients, the frequency was 5/55(9.09%), while 7/125(5.6%) in ischemic ones. The difference in frequencies was 4.03%. There was no significant difference in seizure frequencies between the two groups (p=0.298). Conclusion: This study concluded that there is no significant statistical difference in frequencies of post-stroke seizure in haemorrhagic stroke compared to ischemic stroke patients.