[Transforming growth factor beta in patients with cervical artery dissection]

OBJECTIVE

To evaluate transforming growth factor beta (TGF-β) in patients with cervical artery dissection (CeAD).

MATERIAL AND METHODS

TGF-β was studied by enzyme immunoassay in 74 of 336 patients with CeAD observed at the Research Center of Neurology (Moscow) from 2000 to 2021. The average patient's age at the time of TGF-β study was 41.6±9.8 years; the proportion of women was 51%. TGF-β was studied in the first month of the disease (n=9), for 2-3 months (n=12) and at a later period (mean - 4.3±5.03 years) (n=53). The control group consisted of 20 healthy volunteers, matched for age and sex. Dissection occurred in internal carotid artery (ICA) (n=42), vertebral artery (VA) (n=29), ICA+VA (n=3) and involved 1 artery (n=58) or 2-3 arteries (n=16). Clinical manifestations included ischemic stroke (IS) (n=49), isolated cervical-cephalic headache (n=23), lower cranial nerve palsy (n=2). Pathological CeAD tortuosity was detected by angiography in 13 patients, and a dissecting aneurysm in 15 patients.

RESULTS

TGF-β1 and TGF-β2 were elevated in patients with CeAD patients compared with the control: TGF-β1 - 4990 [3950; 7900] pg/ml vs. 3645 [3230; 4250] pg/ml, p=0.001; TGF-β2 - 6120 [4680; 7900] pg/ml vs. 3155 [2605; 4605] pg/ml, p=0.001. The highest TGF-β1 and TGF-β2 levels were noted at 2-3 months of the disease. There was no correlation between the TGF-β level and various clinical and angiographic parameters.

CONCLUSION

Increased TGF-β level confirms that CeAD patients have connective tissue disorder that underlies the arterial wall weakness. A higher TGF-β level at 2-3 months of CeAD seems to be connected with an active reparative process in arterial wall after dissection. TGF-β can be used as a biomarker of connective tissue dysplasia in patients with CeAD.

Efficiency of Leg Exoskeleton Use in Rehabilitation of Cerebral Stroke Patients

The study aimed to evaluate the effectiveness of functional and motor activity restoration, including the walking function, in patients after an ischemic stroke using the ExoAtlet lower limb exoskeleton.

Patients and methods. A clinical study was carried out on 42 patients who had undergone a cerebral infarction in the mid cerebral artery system with a post-stroke paresis of the leg, and who had undergone a rehabilitation course in a round-theclock hospital during the early recovery period. Patients were randomized into two equal groups comparable in terms of the stroke severity: the patients in group 1 were receiving a standard rehabilitation program (control group), the patients in group 2 were additionally receiving a course of gait rehabilitation using the ExoAtlet exoskeleton - 10 sessions, 5 sessions per week for 14 days.

Results. The study demonstrated the effectiveness of the ExoAtlet exoskeleton used in the rehabilitation of stroke patients over the standard course of rehabilitation. The advantages include a decrease in the hemiparesis degree, an increase in the muscle strength of the paretic limb, an improvement in balance, an improvement and acceleration of the walking process. The obtained results of the instrumental study confirmed the benefits of physical training on the Exoskeleton, which was demonstrated through an increase in stability and balance, as well as through a decrease in the energy consumption index for maintaining the stable verticalization.

Conclusion. The usage of the ExoAtlet exoskeleton increases the effectiveness of rehabilitation measures and improves motor and functional activities of patients who have suffered a cerebral stroke.

[Cervical artery dissection in women: relationships with pregnancy and postpartum period]

OBJECTIVE

To study the frequency of CeAD that developed during pregnancy or in post partum period among all CeADs in women; to study the course of pregnancy in women with prior CeAD.

MATERIAL AND METHODS

162 women (mean age 37.1±4.1 years) with CeAD we examined at the Research Center of Neurology (Moscow), 98% women were studied during last 15 years. 140 women were of childbearing age (≤45 years, mean age - 35±2.8 years). All patients were interviewed whether or not CeAD occurred during pregnancy or in post partum period (CeADPPP). Obstetric history before and after CeAD was studied in 57 women of childbearing age (average age - 35.9±7.3 years at CeAD development).

RESULTS

CeADPPP developed in 6 out of 162 all female patients (3.7%) or of 140 childbearing age patients (4.3%). It occurred 2-6 months (4 patients) and 10 days after delivery (1 patient), or on the 25^th week of pregnancy (1 patient). CeADPPP patients were younger than patients with CeAD out of pregnancy or postpartum period (29.8±8 years vs 35.1±6.7 years, p>0.05). CeADPPP in comparison with CeAD outside these periods more often involved internal carotid artery (ICA) (50% vs 35%, p=0.666), more often occurred in 2-3 arteries (50% vs 31%, p=0.386) and more often was accompanied by dissecting aneurysm development (50% vs 8%, p=0.013). After CeAD, 18 out of 57 patients in whom obstetric history was studied, including 3 patients with postpartum dissection had 29 pregnancies. The pregnancy outcomes were as follows: childbirth (17 pregnancies, 59%), fetal loss (8 pregnancies, 27%) and medical abortion (4 pregnancies, 14%). Delivery occurred on average 4.5±2.061 years after CeAD in women aged 33.0±4.25 years (cesarean section - 15 patients). Fetal loss occurred at 7.4±3.5 weeks of pregnancy in women aged 37.6±3.13 years on average 2.7±1.4 years after CeAD. Fetal loss frequency after CeAD was higher than before it (27% vs 7%, p=0.016). There were no CeAD recurrences during pregnancy and postpartum period in women who had previously undergone CeAD.

CONCLUSION

CeADPPP frequency among all dissections in women is 3.7-4.3%. The risk of CeAD recurrence during pregnancy or the postpartum period after prior CeAD is very low. The risk of fetal loss during 2.7±1.4 years after CeAD is higher than before it (27% vs 7%). Hormonal and growth factors associated with pregnancy and the postpartum period is suggested to contribute to cervical artery wall damage. It is possible that the prolonged action of some of these factors may disrupt the placental vessels formation, predisposing to miscarriage.

[Ischemic stroke at a young age on the context of chronic myeloleukosis]

The article describes the clinical search for diagnosis and treatment of a patient who developed a severe ischemic stroke at a young age, when specifying the cause of which chronic myeloleucosis was identified. The unavailability of patient compliance and non-compliance with the recommended examination at the outpatient stage led to the development of severe complications. It would seem that the diagnosis of chronic myeloid leukemia, which does not represent excessive complexity, with the development of an acute condition in a young patient, such as an ischemic stroke, results in a complex diagnostic search, complicated by developing comorbidities due to general decompensation of the body.

Biomarkers of atrial cardiopathy in patients with different pathogenetic subtypes of ischemic stroke

Studies of the biomarkers of atrial cardiopathy seem to be promising for identifying patients with cryptogenic stroke (CS), in which an intensive search for atrial fibrillation is indicated. Nevertheless, the diagnostic value of these markers and their threshold values require clarification.

Objective: to present the characteristics of echocardiographic markers for atrial cardiopathy and the serum concentration of N-terminal pro-Btype natriuretic peptide (NT-proBNP) in embolic CS versus cardioembolic stroke (CES) and non-cardioembolic stroke (non-CES) to determine the threshold values of parameters with the highest sensitivity and specificity in differentiating CES and non-CES.

Patients and methods. A total of 259 patients with ischemic stroke were examined. The standard examination additionally involved calculation of the parameters that reflected left atrial LA) function (LAF): LA emptying fraction (LAEF), and LA functional index (LAFI). The serum NT-proBNP concentration was also determined in 75 patients.

Results and discussion. The patients with CES versus those with CS and non-CES were characterized by a considerable increase in LA diameter (4.3 [3.5; 4.5] cm vs 3.7 [3.4; 4.0] cm vs 3.7 [3.4; 3.9] cm; p=0.005 and p=0.009, respectively), LAVI (35.7 [30.5; 39.9] ml/m2 vs 28.5 [25.6; 34.6] ml/m2 vs 27.1 [24.5; 31.2] ml/m2 ; p< 0.001) and NT-proBNP level (559 [409; 1144] pg/ml vs 164 [65; 308] pg/ml vs 191 [63; 446] pg/ml; p=0.002 and p=0.019, respectively), as well as by a lower LAEF value [50.3 [48.5; 51.1]% vs 54.7 [51.6; 56.6]% vs 54.9 [52.5; 56.8]%; p< 0.001). The only parameter that showed significant differences between all the three groups (CES, CS, and nonCES) was LAFI (0.24 [0.2; 0.32] units vs 0.37 [0.3; 0.47] units vs 0.40 [0.34; 0.47] units; p<0.00 1), while maintaining the differences in the values for the two groups (CS and non-CES) (p=0.004). The following threshold values of biomarkers were obtained for CES and nonCES; these were a LA diameter of 41.5 mm (p< 0.001), a LAVI of 36.3 ml/m2 (p< 0.001), a LAEF of 51.8% (p< 0.001), a LAFI of 0.28 units (p< 0.001), and an NT-proBNP of 316 pg/ml (p< 0.001). Analysis of the ROC curves and the area under the curve (AUC) revealed that the most informative criteria for sensitivity and specificity were LAEF (79 and 88%, AUC 0.89), NT-proBNP (67 and 91%, AUC 0.89) and LAFI (93 and 72%, AUC 0.81).

Conclusion. The CS group and non-CES one are comparable in the echocardiographic manifestations of atrial cardiopathy and in serum NTproBNP values. LAEF and NT-proBNP concentrations are promising biomarkers to classify CS patients into potential arterio- and cardioembolic types.

[Pulmonary arteriovenous shunt - a rare cause of recurrent stroke due to paradoxical embolism]

Paradoxical embolism is one of the mechanisms of ischemic stroke in patients younger than 45 years of age, due to opening between the right and left chambers of the heart through a patent foramen ovale, an atrial or ventricular septal defect, pulmonary arteriovenous malformations (PAVMs), etc. The PAVMs are structurally abnormal vessels that provide direct capillary-free communication between the pulmonary and systemic circulations, and hence an anatomic "right-to-left" shunt. Most pulmonary malformations are congenital and associated with hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). This publication highlights the issues of pathogenesis, clinical presentation, diagnosis and treatment of this pathology, and also describes a clinical case in which multiple PAVMs caused repeated ischemic strokes.

[Intracerebral hemorrhage in the late period of internal carotid artery dissection]

Cervical artery dissection is the common cause of ischemic stroke in young and middle-age patients. According to our previous studies, dissection is related to arterial wall dysplastic changes, which in their turn are due to mitochondrial cytopathy. The authors describe three male patients who at the age of 53, 25 and 35 years underwent internal artery (ICA) dissection with occlusion of its lumen and subsequent recanalization in one of them. In 3.5 months, 13.5 years and 3 years respectively, patients developed intracerebral hemorrhage (IСH), which was not related to arterial hypertension, cerebral arterial aneurysms and anticoagulants. IСH were located on the side of ICA occluded after dissection (2 patients) or bilaterally in the territory of patent ICA (1 patient). Multivoxel ¹H-MR spectroscopy performed in one patient on 40 and 48 days after ICH revealed a high lactate peak in the externally unchanged hemispheric white matter. It is assumed that mitochondrial cytopathy in patients with dissection may involve large as well as small intracerebral arteries (mitochondrial microangiopathy), which could be the cause of ICH.

Cryptogenic stroke

The paper considers the epidemiology and general etiological characteristics of cryptogenic stroke (CS). It discusses the concept of embolic stroke with an unknown source of embolism. It also characterizes the most significant causes of CS, such as paroxysmal atrial fibrillation, atrial cardiopathy, aortic atheroma, non-stenotic cerebral atherosclerotic plaques, and malignant neoplasms. The paper describes approaches to the diagnosis and secondary prevention of CS and proposes etiological and neuroimaging diagnostic algorithms for CI. Clinical cases are also presented.

[Indicators of homeostasis, inflammation and homocysteine in ischemic stroke in the young age]

AIM

To determine indicators of homeostasis, inflammation and homocysteine in the young-aged patients with ischemic stroke (IS) of different genesis in the subacute and chronic stages.

MATERIAL AND METHODS

Out of 218 patients with IS (mean age 34.7±8.7 years), 55 had stroke due to dissection of the inner carotid or the spinal artery, 28 due to cardioembolia, 38 due to antiphospholipid syndrome (APS), 16 due to cerebral arteritis; 85 patients were classified as having cryptogenic stroke, including 23 with noncerebral thrombosis (coagulopathy of unknown etiology) and 62 with no thrombosis. The control group included 28 healthy people matched for age and sex.

RESULTS

There were 1) an increase in von Willebrand factor and coagulation factor VIII as well as a decrease in plasminogen and an increase in plasmin-inhibitor in IS caused by thrombosis (APS, cardioembolia, coagulopathy of unknown etiology); 2) alterations in erythrocyte aggregation and deformity in cryptogenic stroke; 3) mild or moderate hyperhomocysteinemia, with the exception of patients with APS and arteritis. Linear regression analysis confirmed these relationships. Discriminant analysis identified the clusters of parameters characteristic of APS (an increase in (aPTT), plasminogen, blood sedimentation rate, C-reactive protein) and cardioembolia (decreased protein C and increased hematocrit).

CONCLUSION

The laboratory markers associated with cerebral thrombosis can be used for identification of a prothrombotic state as a cause of IS in the young age. Moderate hyperhomocysteinemia is a risk factor but not a cause of IS. The increase of inflammatory markers in APS suggests a role of infection in its development.

[Pathological changes in extra- and intracranial vessel in young adults in the aspect of sudden death]

AIM

To determine the main causes and pathomorphological characteristic of extra- and intracranial vessel pathological changes in young adults in the aspect of sudden death (SD).

MATERIAL AND METHODS

The authors investigated 10485 SD cases in young adults in the period from 2012 to 2016 (5 years) according to Moscow coroner bureau autopsy data. Morphological, chemical, histological, histochemical methods (staining with hematoxylin and eosin, van Gieson's stain, Masson's trichrome stain) were used.

RESULTS

Sudden death events of young adults are up to 11.93% of all non-violent death cases (81.18% of males, 18.81% - females). The mean age of the male group was 24.6, the female group 29.1. Intracranial vessel pathology was found in 549 cases (5%). Inborn aneurysms were identified as follows: arterial (69%), arteriovenous (26%) and arteriovenous malformations not diagnosed during lifetime (5%). In 14% of cases, ruptured aneurysms were combined with small extracranial ones on the convexital brain surface that show no signs of impairment. Histological investigation of aneurysms of any localization demonstrated the absence of multilayered vessel wall structure - elastic compartment with signs of disorganization, twists or total connective tissue replacement. In 93% of deaths caused by intracranial vessels rupture, the following signs of connective tissue dysplasia (CTD) were found: tall height, asthenic constitution, breastbone and cardiovascular pathology, mitral valve prolapse, aorta hypoplasia and so on. During the detailed vessel investigation in CTD group, a complex of pathological characteristics (total hypoplasia, wall thinning, S-form vertebro-basilar system vessels) was found.

CONCLUSION

CTD is a pathology that becomes a risk factor for intracranial aneurysms formation and rupture in case of severe physical activity or emotional stress. Hemorrhagic infarct or non-traumatic subarachnoidal hemorrhage development lead to SD in young adults. Prompt CTD markers identification will provide new possibilities to prevent SD of youth.