[Cardiac complications and heart rhythm variability in the late post-stroke period].

The aim of this prospective study was to elucidate the relationship between cardiac complications and heart rhythm variability (HRV) in 90 patients (age median 58 (53;67) years) with the sinus rhythm after ischemic stroke. 24-hr Holter monitoring 21 days after stroke was used for temporal and spectral analysis of HRV. The follow-up period lasted 23 (12; 45) months. Ten (11%) patients of this group developed acute myocardial infarction, unstable angina, acute cardiac failure or sudden cardiac death. The remaining 80 (89%) patients constituted group 2. The two groups were matched for the duration of prospective observation, sex, ischemic stroke subtype, the size and localization of brain infarction, multiplicity of focal cerebral lesions, severity of neurologic disorders (Rankin scale), the history of myocardial infarction, the presence of diabetes and chronic heart failure. Patients of group 1 were older in the end of the acute stroke period than those of group 2 (68 (61;72) and 57 (51;66) years) respectively. They, more frequently suffered CHD (stable angina) and had lower spectral characteristics of HRV (p < 0.05).

[Cardioneurology: the up-to-date key positions and the future prospects].

The up-to-date key positions and the future prospects of cardioneurology were analyzed. The wide range of questions of cardioneurology was represented and the necessity of the interdisciplinary approach to the diagnostics, treating and prevention of the cerebrovascular diseases were proved. It was pointed that the studied problems are the priority directions in angioneurology and have great social and clinical importance.

[Central hemodynamics and cerebrovascular disorders in patients with idiopathic arterial hypotension].

A total of 65 patients (mean age 40.2 +/- 8.1 yr) with neurologic and neuropsychological disorders associated with long-term idiopathic arterial hypotension (IAH) were studied to estimate the state of their central blood circulation. Neuropsychological conditions were estimated from the state of higher psychic functions, such as memory speech, gnosis, praxis, cognition, attention, counting, writing, and reading abilities. Central hemodynamics was studied by 24 hr monitoring arterial pressure and echocardiography. Group 1 included patients without neurologic problems (n = 19), group 2 consisted of patients with early manifestations of chronic cerebrovascular insufficiency (n = 46, 71%). They were older than patients of group 1 and had a long history of IAH. It was shown that most patients presented with stably reduced systolic and diastolic AP and non-dipper type of low 24-hour SAD index. The cardiac index was elevated due to increased left ventricular ejection fraction (group 1) or increased heart rate (group 2). The severity of neuropsychic disorder was negatively related to SAD and DAD indices and positively to systolic hypotension time.

[Cardioneurological aspects of antiplatelet therapy in secondary prevention of cardiovascular diseases].

The paper reflects contemporary views of the role of antiplatelet therapy in secondary prevention of cardiovascular diseases in patients with coronary heart disease and ischemic stroke. On the basis of evidence based medicine analytical characteristics of all antiplatelet drugs subjected to clinical trials in the world are presented. Advantages and imperfectness of each agent both as monotherapy and used in combinations are demonstrated. Main principles of selection of antiplatelet drugs in patients after ischemic stroke, myocardial infarction, or in stable manifestations of coronary atherosclerosis are also given.

[Comparative clinical and anatomic characteristic of patients with patent foramen ovale in cryptogenic and noncryptogenic stroke].

In order to study anatomical and functional characteristics of patent foramen ovale (PFO) in patients with cryptogenic stroke and with other stroke subtypes we examined 56 stroke patients (male--35, female--21, age 46.7 +/- 16.5 years) with PFO and ischemic stroke. Diagnosis of PFO was made by transesophageal echocardiography (TEE), contrast transcranial Doppler monitoring (C-TCD), contrast transthoracic echocardiography (C-TTE). Group 1 was made up of patients with definite stroke cause (cardioembolic, lacunar, atherotrombotic) (n=40), and group 2--of patients with cryptogenic stroke (n=16). Patients in group 2 were younger than patients in group 1 (38.7 +/- 13.4 and 50.4 +/- 16.5 years, p < 0.05) and had slight neurological symptoms. These patients also more frequently had avalvular, or "window-like" anatomic types of PFO (2 [13%] and 4 [27%] patients, respectively), combination of large anatomic size (3 mm and larger) and functional level of PFO (3 degree of the right-to-left shunt by C-TCD) (p < 0.05).

[Pathogenetic significance of patent foramen ovale in patients with the determined cause of ischemic insult].

The prevalence of open oval window (OOW) in patients with different types of ischemic insult and the possibility of independent pathogenetic contribution of OOW to brain injury were evaluated by examining 85 patients (mean age 53 +/- 14 yr) with cardioembolic (CES), lacunar (LS), and other subtypes of ischemic insult. CT and MRT of the head, duplex scanning of head arteries, contrast transcranial monitoring middle cerebral arteries, standard and contrast transthoracic and transoesophageal echocardiography revealed OOW in 40% of the patients. It had small anatomic and functional size and a tunnel-like shape. The presence of an interatrial shunt was unrelated to the degree of neurologic deficit, the size and location of brain injuries, the number of ischemic foci. It is concluded that OOW has no pathogenetic significance of its own and makes no contribution to brain injury in stroke-affected patients.

[Cerebral circulation in chronic hypertensive encephalopathy].

Cerebral blood supply was studied in 123 patients with stage III hypertensive encephalopathy (HE) in the absence of occlusion of main head arteries. Duplex scanning was used to measure blood flow rate in common carotid (CCA), vertebral (VA) and medial cerebral (MCA) arteries. Cortical cerebral blood flow (CBF) was measured by single-photon emission CT using 99mTc- ceretec. Normal and stable blood flow in CCA and VA was documented at all HE stages whereas it decreased in MCA of patients with HE II-III. Cortical CBF in frontal and parietal segments in HE II-II was higher than in HE I (p < 0.05). These findings suggest impaired subcortical perfusion and correlation of the discrepancy between cortical and subcortical blood supply with the severity of HE. Leukoaraosis is an indicator of hypoperfusion.

[Paradoxical embolism in patients with ischemic stroke].

The present study included 84 patients with ischemic stroke of known and unknown etiology. The risk of paradoxical embolism (PE) was evaluated using contrast transthoracic echocardiography, contrast transcranial Doppler monitoring, and transoesophagal echocardiography. The majority 64%) of the patients with strokes of known etiology were found to be predisposed to PE because they had the patent interatrial foramen (PIF) and pulmonary shunt (51 and 13 respectively). PIF was of small functional and anatomical size. Predisposition to PE in most patients with cryptogenic stroke (94%) was due to the presence of PIF (in 88%) and was often the sole cause of the stroke. These patients frequently had the shunt of a large functional size.

[Cerebral hemodynamics and endothelium function in patients with cerebrovascular pathology treated by teveten].

Teveten (eprosartan mesilate) was used as a monotherapy or in combination with hypotiazide (12,5 mg/day) in dosage 600 mg once a day for treatment of 20 patients with cerebrovascular pathology (chronic cerebrovascular insufficiency, consequences of brain ischemica in the presence of arterial hypertension stage I-II, or higher borderline levels of normal blood pressure (BP). Treatment duration was 12 weeks, 24-h monitoring of BP was made some indices of cerebral blood flow, hemodynamics and peripheral vessels reaction were registered. Modulating antihypertensive effect of Teveten was found, statistically significant reduction of systolic BP did not result in worsening of cerebral hemodynamics. Moreover, there was an improvement of endothelial function. Therefore, teveten may be recommended for treatment of patients with cerebrovascular pathology both with arterial hypertension and higher borderline BP.

[Risk of recurrent cerebral embolism in isolated and combined cardial pathology in patients with cardio-embolic stroke]. / Risk povtornoi tserebral'noi émbolii pri izolirovannoi i sochetannoi kardial'noi patologii u bol'nykh s kardioémbolicheskim insul'tom.

To study cerebral microembolism and focal impairment of the brain in patients with isolated and combined cardiac affection, we examined 84 patients who had survived cardioembolic stroke (CES). The examination included computed tomography of the head, echocardiography and transcranialdopplerographic monitoring of microembolic signals (MES). Group 1 consisted of 53 (63.1%) patients with one source of cardiocerebral embolism, group 2-31 (36.9%) patients with two potential causes of cardial embolic complications. In group 2 average number of documented MES (3[1;5]) and average number of cerebral ischemic foci (2[1;2]) were greater than those of group 1-2[1;4] and 1[1;1], respectively. As to the size of the lesion, it was found that small, middle-size and large foci were also visualized in group 2 more frequently. Thus, combination of two sources of cerebral embolism observed in 1/3 of CES enhances cardiogenic embologenic potential and probability of microembolism transformation into cerebral focal lesion as a result of potentiation of different ways of thrombogenesis.

[Cerebral perfusion in patients with arterial hypertension and chronic forms of brain vascular pathology]. / Tserebral'naia perfuziia u bol'nykh arterial'noi gipertoniei i s khronicheskimi formami sosudistoi patologii golovnogo mozga.

AIM: To examine cerebral perfusion in patients with dyscirculatory encephalopathy and residual disorders of cerebral circulation in arterial hypertension. MATERIAL AND METHODS: Duplex scanning of extra- and intracranial arteries, computed tomography of the head were performed in 26 hypertensive patients with chronic vascular pathology of the brain. Cerebral perfusion was studied by the evidence obtained at single-photon emission computed tomography. RESULTS: Impaired segmental perfusion of the brain, primarily of frontal and temporal location, was detected in 88.5% patients. Occlusive lesions of extra- and intracranial arteries were accompanied by significant deterioration of the perfusion while visualization of leukoaraosis was associated with high perfusion in the anterior frontal compartments indirectly pointing to defects in autoregulation of cerebral circulation. It was found that different correlations exist between perfusion of various segments of the brain and systemic arterial pressure. This is explained by functional and hemodynamic heterogenicity of different brain regions. CONCLUSION: Specific features of cerebral perfusion in patients with chronic forms of vascular brain pathology should be considered in planning antihypertensive therapy because of the risk of focal hypoxia and even ischemia in an inadequate fall of arterial pressure.

[Pathogenetic assessment of cardiac arrhythmia and myocardial ischemia in hemodynamic stroke]. / Patogeneticheskaia otsenka narushenii ritma serdtsa i ishemii miokarda pri gemodinamicheskom insul'te.

330 patients with ischemic stroke entered the trial. They were divided into two groups: 72 (21.8%) patients with hemodynamic stroke (group 1) and the rest 258 (78.2%) patients with other pathogenetic subtypes of stroke (group 2). Heart rhythm and myocardial ischemia were studied using ECG and Holter monitoring. Electrocardiographically, hemodynamic stroke is characterized by frequent ventricular extrasystole, sick sinus syndrome and transient atrioventricular block of the second and third degree with pauses 2 s and longer, ventricular fibrillation and painless myocardial ischemia. Perpetual and paroxysmal atrial fibrillation and paroxysmal ventricular tachycardia are not pathognomonic for hemodynamic stroke though these disorders can be also considered as independent pathogenetic factors of hemodynamic cerebral focal lesion.

[Echocardiographic changes associated with risk of developing embolic complications in patients with ischemic stroke]. / Ekhokardiograficheskie izmeneniia, sopriazhennye s riskom razvitiia émbolicheskikh oslozhnenii, u bol'nykh s ishemicheskim insul'tom.

AIM: To study echocardiographic parameters associated with embolic complications in patients with cardioembolic and other pathogenetic subtypes of ischemic stroke. MATERIAL AND METHODS: 330 patients with ischemic stroke (IS) were examined. Transthoracal echocardiography was made in all the patients, transesophageal echocardiography was performed in 53 (16.1%) patients. The patients were divided into two groups: 104 (31.5%) patients who survived cardiocerebral embolism (group 1), 226 (68.5%) patients with other pathogenetic subtypes of stroke (group 2). RESULTS: Cardiac pathology was detected in 220 of 330 (66.7%) examinees with ischemic heart disease in 50.0% and 51.3% patients of group 1 and 2, respectively; infectious-inflammatory diseases--in 27.9 and 4.4%, respectively (p < 0.0001), other diseases (mitral prolapse, aneurysm and interatrial defect, idiopathic arhythmia) in 25.0 and 5.3% patients, respectively (p < 0.0001). Left atrial myxoma was diagnosed in 1.9% patients of group 1. CONCLUSION: Echocardiographic changes associated with a risk of embolic complications were visualized in all pathogenetic subtypes of ischemic stroke. In cardioembolic stroke echocardiography detected most frequently prolapse with myxomatous degeneration of the cusps and mitral vegetations, mitral failure, calcinosis of the mitral ring, local hypokinesia of the left ventricle, dilation and thrombosis of the left atrium. Rare changes, indicating cerebral embolism, include replaced aortic and mitral valves, mitral stenosis, cardiac tumor, aneurysm and defect of the interatrial septum.

[Comparative assessment of persistent and paroxysmal atrial fibrillation as causes of cardiocerebral embolism]. / Sravnitel'naia otsenka postoiannoi i paroksizmal'noi fibrilliatsii predserdii v patogeneze kardiotserebral'noi émbolii.

In 66 patients with embolic stroke of cardiac origin (33 with persistent and 33 with paroxysmal atrial fibrillation) transthoracic and transesophageal (21 patients, 31.2%) echocardiography was used for detection of atrial thrombosis. Lone atrial fibrillation was significantly more frequent among patients with paroxysmal atrial fibrillation. Frequency of thrombosis of left atrial appendage was similar in patients with nonrheumatic persistent and paroxysmal atrial fibrillation.

[Perpetual cardiac fibrillation and predictors of sudden cardiac arrhythmic death in patients with ischemic stroke]. / Postoiuannaia forma mertsatel'noi aritmii i prediktory vnezapnoi kardial'noi aritmicheskoi smerti u bol'nykh s ishemicheskim insul'tom.

AIM: To study predictors of sudden cardiac arrhythmic death in patients with perpetual cardiac fibrillation (PCF) and ischemic stroke. MATERIAL AND METHODS: 230 patients with ischemic stroke were examined. 22 (9.6%) patients of them (group 1) had PCF, 208 (90.4%) patients (group 2) had sinus rhythm. The groups were matched by sex, stage of ischemic stroke, presence of ischemic heart disease. Echocardiography and Holter monitoring were made in all the examinees. RESULTS: Zones of left ventricular dyskinesia and high-grade extrasystoles occurred more frequently in group 1. Ventricular extrasystoles were also frequent in this group. A close correlation was found between the zones of left ventricular dyskinesis and ventricular extrasystoles of high gradations. CONCLUSION: Thus, most of the patients with ischemic stroke and PCF have ventricular arrhythmia resultant from systolic dysfunction of the left ventricle and related to the risk of sudden cardiac death.

[Cardiac arrhythmia in cardiac embolism]. / Narusheniia ritma serdtsa pri kardioémbolicheskom insul'te.

To study cardiac arrhythmia in patients with cardiocerebral embolism, we examined 330 patients with ischemic stroke using ECG and Holter monitoring. 33 patients were control. Group 1 consisted of 104(31.5%) patients with cardioembolic stroke, group 2--of 226(68.5%) patients with other pathogenetic stroke subtypes. Number of patients with rare and frequent supra- and ventricular extrasystole in groups 1 and 2 was not essentially different. Paroxysms of supra- and ventricular tachycardia, variants of sick sinus syndrome (SSS) and transitory atrioventricular block (AV block) of the second and third degree were identified with comparable frequency in groups 1 and 2 (0.9 to 5.8% patients). Paroxysmal atrial fibrillation (AF) was registered in 31.8% of group 1 patients and 15.9% of group 2 patients. Permanent AF occurred in 31.8 and 7.5% patients of groups 1 and 2, respectively (p < 0.00001). Thus, cardiocerebral embolism is observed most frequently in paroxysmal and permanent forms of AF. Variants of extrasystole, paroxysmal supra- and ventricular tachycardia, SSS and AV-block are not associated with embolic complications.

[Echocardiographic alteration in patients with hemodynamic stroke]. / Ekhokardiograficheskie izmeneniia u bol'nykh s gemodinamicheskim insul'tom.

Echocardiography was made in 330 patients with ischemic stroke. Group 1 consisted of 72(21.8%) patients with hemodynamic stroke, the rest 258(78.2%) patients (group 2) had other pathogenetic subtypes of stroke. Chronic cardiac pathology was represented by postinfarction cardiosclerosis (38.9 and 17.8% for groups 1 and 2, respectively, p < 0.001) and continuous atrial fibrillation (15.3 and 15.1%, respectively, p > 0.05). Stroke volume of the left ventricle (LV), cardiac output and ejection fraction of the LV were significantly less than in group 2 and in control group but within normal range. The number of group 1 patients having local LV dyskinesia and transitory painless myocardial ischemia was significantly higher than in group 2 (p < 0.001). Painless ischemia correlated with local dyskinesia of the LV (p < 0.02). As transitory myocardial ischemia may deteriorate LV contractility and provoke excessive fall of blood pressure, local LV dyskinesia caused by postinfarction changes seems to be a principal and stable echocardiographic sign of developing hemodynamic stroke.

[Cardiac pathology in various in various pathogenetic subtypes of ischemic stroke]. / Kardial'naia patologiia pri razlichnykh patogeneticheskikh podtipakh ishemicheskogo insul'ta.

Heart pathology was studied in various pathogenetic subtypes of ischemic stroke. A total of 330 stroke patients were divided into 4 groups. Group 1 consisted of 104 (31.5%) patients with cardioembolic stroke, group 2--of 72 (21.8%) with hemodynamic, group 3--of 71 (21.5%) patients with atherothrombotic and group 4--of 83 (25.2%) patients with lacunar stroke. Cardiac pathology was found in all patients of group 1 (ischemic heart disease-50.0%, inflammatory-infectious lesions-27.9%, other lesions-22.1%), in 49 (68.1%) patients of group 2, 36 (50.7%) of group 3 and 31 (37.3%) of group 4. Ischemic heart disease was prevalent (85.7, 86.1, 83.9% vs group 1). Potential sources of cardiogenic cerebral embolia were found in patients of all the groups: 100, 62.5, 43.7 and 33.7%, respectively. Thus, most patients with ischemic stroke have different heart defects related to the subtype of ischemic stroke. Potential causes of cardiocerebral embolism can be detected in any subtype of ischemic stroke.

[Characteristics of cerebral microembolic signals and focal lesions of the brain in different causes of cardiogenic embolism]. / Kharakteristika tserebral'nykh mikroémbolicheskikh signalov i ochagovoe porazhenie golovnogo mozga pri razlichnykh tipakh istochnikov kardiogennoi émbolii.

To study quantitative and qualitative characteristics of microembolic signals (MES) and specific features of a focal damage to the brain depending on the site of the embolic substrate in patients with cardioembolic stroke (CES), we examined 84 patients who survived CES. 38 (45.2%) of them had an acute stage, 46 (54.8%)--a residual stage. Group 1 comprised 42 patients with cardial pathology characterized by intrachamber formation of the embolus and 2 patients with an open oval window. Group 2 consisted of 40 (48%) patients with diseases promoting formation of emboli on the cardiac valves. The highest frequency, intensity and duration of MES in CES were registered in patients of group 2 while the number of ischemic focuses was greater in patients of group 1. This may be explained by the fact that intensity and duration of cardiogenic MES depend more on acoustic density of the embolus than on its size. Therefore, the site of the embologenic substrate together with quantitative and qualitative MES characteristics is the key factor of a high risk of cardiocerebral embolic complications.

[Cardiogenic ischemic strokes: pathogenetic aspects]. / Patogeneticheskie aspekty kardiogennykh ishemicheskikh insul'tov.

Eighty-three patients with acute ischemic stroke (56 men and 27 women, mean age 90.1 +/- 10.8 years) were examined in order to elucidate the significance of paroxysmal heart rhythm disorders and silent myocardial ischemia and determine the pattern of hemorheological changes. Traditional clinical instrumental examinations were supplemented by Holter monitoring and measurements of a wide spectrum of hemostatic and hemorheological values. Cardiogenic ischemic strokes were pathogenetically heterogeneous. Holter monitoring helped detect the significance of paroxysmal atrial fibrillation in the pathogenesis of embolic cardiogenic stroke. One of the key factors in development of hemodynamic cardiogenic stroke was transitory bradyarrhythmia and deterioration of left-ventricular contractility. Cardiogenic strokes are associated with hemostatic activation with predominant changes in the plasma hemostasis, which dictates purposeful hemocorrection.