#спасибодоктор COVID19
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Patient G., 42 years old

The final diagnosis:
An open oval window. Acute violation of cerebral circulation in the right hemisphere, according to ischemic type in the basin of the right middle cerebral artery from 14.07.2017. Operation of endovascular closure of an open oval window with implantation of a Figulla Flex II ASD 23/25 mm occluder from 16.05.2018.

The history of life

  • Throughout my life, I felt satisfactory, and I did not go to the doctors.
  • Heredity is not burdened
  • He denies any bad habits
  • Past illnesses: acute respiratory viral infections 2-3 times a year
  • Concomitant pathology: chronic gastritis
  • Gynecological history : no specific features. 2 pregnancies, 2 deliveries, taking oral contraceptives for 5 months

Anamnesis of the disease

  • In July 2017, complaints of numbness of the torso, speech disorders such as “porridge in the mouth”, weakness in the left half of the torso
  • Hospitalization in the Pirogov medical CENTER
  • onmc was diagnosed in the right hemisphere (CT-signs of ischemic stroke in the right SMA basin)
  • systemic thrombolysis with alteplase (without effect) – CT: occlusion of the M1 segment of the right artery srednemirovoj
  • cerebral angiography followed by stent-Retriever endovascular thrombectomy with positive effect (blood Flow TICI III)
  • Echo KG: thinning of the middle third of the MPP for 12 mm (MPP aneurysm), LLC, small atrial shunt. SDLA is 28 mmHg.
  • DS veins of the lower extremities: bilateral deep vein thrombosis of the lower leg, sural veins of the right lower limb are non-inclusively thrombated, the tip of the thrombus is not fixed for 15 mm.
  • NOAG therapy for 2 months

Cerebral angiography (on the right)

Mechanical thrombectomy with a standard Retriever

After thrombectomy (blood flow TICI III)

Interpretation of risk on the RoPE scale

ПредикторБаллПациентка

Артериальная гипертензия (отсутствие)

+1

1

Сахарный диабет (отсутствие)

+1

1

 Отсутствие ОНМК или ТИА в анамнезе

+1

1

Некурящий пациент

+1

1

 Наличие коркового инсульта

+1

0

Возраст (лет)

18-29

+5

30-39

+4

40-49

+3

3

50-59

+2

60-69

+1

≥70

0

Максимальный балл

10

7

Interpretation of risk on the RoPE scale

Балл RoPEВероятность взаимосвязи ОНМК  с ООО (95% доверительный  интервал)Ожидаемая вероятность  рецидива ОНМК/ТИА в  течение 2-х лет

0-3

0% (0–4)

20% (12–28)

4

38% (25–48)

12% (6–18)

5

34% (21–45)

7% (3–11)

6

62% (54–68)

8% (4–12)

7

72% (66–76)

6% (2–10)

8

84% (79–87)

6% (2–10)

9-10

88% (83–91)

2% (0–4)

At receipt

  • The condition is satisfactory
  • General and biochemical blood analysis, General urine analysis-without features
  • Smad: indicators of the daily blood pressure profile within normal values
  • Doppler ultrasound of the brachiocephalic arteries: Thickening of TIM
  • DS veins of the lower extremities: Sapheno-femoral anastomosis on both sides are not enlarged, compressed to the end, without signs of thrombosis, ostalnye valves are sufficient. Blood flow on both obvs is in phase, synchronized with breathing
  • Consultation of a neurologist: Taking into account the ischemic type of onsc against the background of LLC, it is recommended to conduct an endovascular closure of the LLC for the prevention of repeated onsc
  • Therapy: acetylsalicylic acid enteric form 100 mg/day, clopidogrel 75 mg/day

ECHO KG

  • the heart cavities are not enlarged, the walls are not thickened, and the contractility of the myocardium is satisfactory. No areas of violation of local contractility were found. Diastolic function of the LV myocardium is not impaired. There are no signs of pulmonary hypertension. Hemodynamically insignificant valvular regurgitations
  • Increased excursion of the MPP, alternately bulges out in the LP, PP cavity up to 0.7 cm

STATE OF EMERGENCY-ECHO

  • Aneurysm of the atrial septum 1. 7×0. 7 cm.
  • No discharge at rest and single bubbles after a bubble test.

STATE OF EMERGENCY-ECHO

Transcranial dopplerography

The size of the bubbles:

  • Agitated saline solution of 60 microns (40-100)
  • Agitated Phys. Solution with blood of 52 microns (24-75)

Bubbles of this size do not survive after passing through the lungs

Transcranial dopplerography (TCD)

Justification for endovascular closure of an LLC

  • It is characterized by ischemic type
  • LLC in combination with aneurysm MPP
  • LLC size > 2 mm
  • thrombophlebitis of the right popliteal vein
  • bypass blood flow from right to left during the Valsalva test

The revelation of the occluder

A stability test

End result

Intraoperative transcranial dopplerography

Before surgery
After operation

TCD after the procedure

Control emergency-ECHO with contrast

Repeat ECHO KG 4 months after the procedure

An occluder is located in the Central part of the MPP. In the Central nervous system, no blood discharge was detected, including on the background of a Valsalva test. Additional formations are not rendered on the occluder. Systolic pressure in the pulmonary artery is 29 mmHg.