neurosurgeryНейрохирургияRussian journal of neurosurgery1683-32952587-7569Издательский дом "МедИНК"10.17650/1683-3295-2023-25-4-68-78neurosurgery-1452Research ArticleОРИГИНАЛЬНАЯ РАБОТАORIGINAL REPORTОценка результатов лечения злокачественного ишемического инсульта в бассейне средней мозговой артерииAssessment of the results of treatment of malignant middle cerebral artery infarctionhttps://orcid.org/0000-0003-3942-7442Сехвейл СалахМ. М.Sehweil SalahM. M.

344022 Ростов-на-Дону, пер. Нахичеванский, 29

29 Nakhichevansky Ln., Rostov-on-Don 344022

salahsehweil@yandex.ruhttps://orcid.org/0000-0001-7093-9548ГончароваЗ. А.GoncharovaZ. A.

344022 Ростов-на-Дону, пер. Нахичеванский, 29

29 Nakhichevansky Ln., Rostov-on-Don 344022

ФГБОУ ВО «Ростовский государственный медицинский университет» Минздрава РоссииРоссияRostov State Medical University, Ministry of Health of RussiaRussian Federation2023270120242546878Copyright © Сехвейл Салах М.М., Гончарова З.А., 20242024Сехвейл Салах М.М., Гончарова З.А.Sehweil Salah M.M., Goncharova Z.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.therjn.com/jour/article/view/1452Введение

Введение. Обширное ишемическое поражение при злокачественном ишемическом инсульте в бассейне средней мозговой артерии (СМА) является причиной развития массивного отека полушария головного мозга, приводящего к возникновению дислокационного синдрома и в большинстве случаев к летальному исходу. Декомпрессивная гемикраниэктомия – более эффективный способ лечения злокачественного ишемического инсульта, чем консервативная терапия.

Цель исследования – оценить эффективность лечения злокачественного ишемического инсульта в бассейне СМА.

Материалы и методы

Материалы и методы. Проанализированы истории болезни 57 пациентов со злокачественным ишемическим инсультом в бассейне СМА, из них 64,9 % составили женщины и 35,1 % – мужчины. В исследование были включены пациенты в возрасте от 49 до 90 лет, в среднем – 72,7 года. Все пациенты были разделены на 2 группы: пациенты 1‑й группы (n = 47, 82,5 %) получали только консервативное лечение; пациенты 2‑й группы (n = 10, 17,5 %) подверглись хирургическому лечению.

Результаты

Результаты. У пациентов 1‑й группы продолжительность нахождения в стационаре составила от 2 до 73 дней (в среднем 14,4 ± 1,8 дня). Летальный исход в группе консервативного лечения был зарегистрирован в 46,8 % случаев в условиях стационара в срок от 2 до 21 дня (в среднем 7,7 ± 1,7 дня). Дислокационный синдром и его последствия были причиной летального исхода у 90,9 % пациентов 1‑й группы в условиях стационара по данным патологоанатомического исследования.

У пациентов 2‑й группы продолжительность нахождения в стационаре варьировала от 22 до 33 дней (в среднем 19,6 ± 4,3 дня). Послеоперационная летальность составила 40 %. Патологоанатомическое обследование показало, что причиной летального исхода явились нарастание дислокационного синдрома и его последствия.

Заключение

Заключение. Злокачественный ишемический инсульт в бассейне СМА является наиболее тяжелой формой ишемического инсульта и характеризуется стойкой инвалидизацией пациентов. Несмотря на выполнение декомпрессивной гемикраниэктомии пациентам со злокачественным ишемическим инсультом в бассейне СМА, сохраняется высокий процент летальных исходов, основной причиной которых является развитие дислокационного синдрома.

Background

Background. A vast ischemic lesion in cases of malignant middle cerebral artery infarction causes a massive edema of the affected cerebral hemisphere, which leads to development of the dislocation syndrome and, in most cases, death. Decompressive hemicraniectomy is a more effective method for treatment of malignant ischemic infarction, than conservative therapy.

Aim

Aim. Evaluation of the effectiveness of treatment of malignant middle cerebral artery infarction.

Materials and methods

Materials and methods. Analysis was carried out of the case histories of 57 patients with malignant middle cerebral artery infarction, out of which number 64.9 % were women and 35.1 % were men. The patients’ ages varied from 49 to 90 years, with the average of 72.7 year. All patients were divided into two groups: Group 1 patients (n = 47, 82.5 %) received only conservative therapy, while Group 2 patients (n = 10, 17.5 %) were subjected to surgical treatment.

Results

Results. The in-hospital stay of Group 1 patients varied from 2 to 73 days (the mean stay being 14.4 ± 1.8 days). Lethality in the conservative therapy patients was 46.8 % during the in-hospital stay varying from 2 to 21 days, with the average of 7.7 ± 1.7 days. Based on the postmortem examination, dislocation syndrome and its consequences were the cause of death in 90.9 % of the patients, who received in-hospital conservative therapy.

The in-hospital stay of Group 2 patients varied from 22 to 33 days, with the average of 19.6 ± 4.3 days. The postoperative mortality was 40 %. The postmortem examination showed that the cause of the deaths was exacerbation of the dislocation syndrome and its consequences.

Conclusion

Conclusion. Malignant ischemic syndrome in the territory supplied by the middle cerebral artery is the most severe form of ischemic infarction accompanied by constant disability of patients. Despite decompressive hemicraniectomy, lethality for the patients with malignant ischemic syndrome remains high, the principal cause being development of the dislocation syndrome.

злокачественный ишемический инсультдекомпрессивная гемикраниэктомиясредняя мозговая артериядислокационный синдромmalignant ischemic infarctiondecompressive hemicraniectomymiddle cerebral arterydislocation syndromeReferencesHacke W., Schwab S., Horn M. et al. Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996;53(4):309–15. DOI: 10.1001/archneur.1996.00550040037012Hacke W., Schwab S., Horn M. et al. Malignant’ middle cerebral artery territory infarction: clinical course and prognostic signs. Arch Neurol 1996;53(4):309–15. DOI: 10.1001/archneur.1996.00550040037012Kasner S.E., Demchuk A.M., Berrouschot J. et al. Prediction of fatal brain edema in massive hemispheric ischemic stroke. Stroke 2001;32(9):2117–23. DOI: 10.1161/hs0901.095719Kasner S.E., Demchuk A.M., Berrouschot J. et al. Prediction of fatal brain edema in massive hemispheric ischemic stroke. Stroke 2001;32(9):2117–23. DOI: 10.1161/hs0901.095719Дашьян В.Г., Талыпов А.Э. Декомпрессивная краниотомия в лечении инфарктов больших полушарий головного мозга. Нейрохирургия 2011;4:8–15.Dashyan V.G., Talypov A.E. Decompressive craniotomy in the treatment of cerebral hemispheric infarcts. Nejrohirurgiya = Russian Journal of Neurosurgery 2011;4:8–15. (In Russ.).Джинджихадзе Р.С., Древаль О.Н., Лазарев В.А. Декомпрессионная гемикраниэктомия при обширном инсульте в бассейне средней мозговой артерии. Журнал «Вопросы нейрохирургии» имени Н.Н. Бурденко. 2012;76(3):69–74.Dzhindzhihadze R.S., Dreval’ O.N., Lazarev V.A. Decompressive hemicraniectomy in extensive ischemic middle cerebral artery stroke. Zhurnal Voprosy neirokhirurgii im. N.N. Burdenko = Burdenko’s Journal of Neurosurgery 2012;76(3):69–74. (In Russ.).Hacke W. Decompressive surgery for malignant middle cerebral artery territory infarction. Pract Neurol 2002;3:144–53.Hacke W. Decompressive surgery for malignant middle cerebral artery territory infarction. Pract Neurol 2002;3:144–53.Gulensoy B., Karaty M., Erdem Y. et al. Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Turk Neurosurg 2016;26(5):704–8. DOI: 10/5137/1019-5149.JTN.13241-14.1Gulensoy B., Karaty M., Erdem Y. et al. Decompressive hemicraniectomy for malignant middle cerebral artery infarction. Turk Neurosurg 2016;26(5):704–8. DOI: 10/5137/1019-5149.JTN.13241-14.1Крылов В.В., Никитин А.С., Дашьян В.Г. и др. Хирургия массивного ишемического инсульта. М.: ГЭОТАР-Медиа, 2016. 136 с.Krylov V.V., Nikitin A.S., Dashyan V.G. et al. Surgery for massive ischemic stroke. Moscow: GEOTAR-Media, 2016. 136 p. (In Russ.).Никитин А.С., Буров С.А., Петриков С.С. и др. Декомпрессивная краниотомия у больных со злокачественным течением массивного ишемического инсульта. Нейрохирургия 2014;3:23–9.Nikitin A.S., Burov S.A., Petrikov S.S. et al. Decompressive craniotomy at patients with malignant course of massive ischemic stroke. Nejrohirurgiya = Russian Journal of Neurosurgery 2014;3:23–9. (In Russ.).Vahedi K., Vicaut E., Mateo J. et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive carniectomy in malignant middle cerebral artery infarction (DECIMAL trial). Stroke 2007;38(9):2506–17. DOI: 10.1161/STROKEAHA.107.485235Vahedi K., Vicaut E., Mateo J. et al. Sequential-design, multicenter, randomized, controlled trial of early decompressive carniectomy in malignant middle cerebral artery infarction (DECIMAL trial). Stroke 2007;38(9):2506–17. DOI: 10.1161/STROKEAHA.107.485235Kimberly T.W., Sheth K.N. Approach to severe hemispheric stroke. Neurology 2011;76(7 Suppl 2):S50–S6. DOI: 10.1212/WNL.0b013e31820c35f4Kimberly T.W., Sheth K.N. Approach to severe hemispheric stroke. Neurology 2011;76(7 Suppl 2):S50–S6. DOI: 10.1212/WNL.0b013e31820c35f4Marklund N. Decompressive carniectomy, ICP monitoring and secondary necrosectomy as treatment options in patients presenting with malignant ischemic infarctions extending beyond the middle cerebral artery territory. Acta Neurochir (Wien) 2018;160(1):91–3. DOI: 10.1007/s00701-017-3331-9Marklund N. Decompressive carniectomy, ICP monitoring and secondary necrosectomy as treatment options in patients presenting with malignant ischemic infarctions extending beyond the middle cerebral artery territory. Acta Neurochir (Wien) 2018;160(1):91–3. DOI: 10.1007/s00701-017-3331-9Huttner H.B., Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009;8(10):949–58. DOI: 10.1016/S1474-4422(09)70224-8Huttner H.B., Schwab S. Malignant middle cerebral artery infarction: clinical characteristics, treatment strategies, and future perspectives. Lancet Neurol 2009;8(10):949–58. DOI: 10.1016/S1474-4422(09)70224-8Heiss W.D. Malignant middle cerebral artery infarction: pathophysiology and imaging for early diagnosis and management decisions. Cerebrovasc Dis 2016;41(1–2):1–7. DOI: 10.1159/000441627Heiss W.D. Malignant middle cerebral artery infarction: pathophysiology and imaging for early diagnosis and management decisions. Cerebrovasc Dis 2016;41(1–2):1–7. DOI: 10.1159/000441627Wijdicks E.F.M. Hemicraniotomy in massive hemispheric stroke: a stark perspective on a radical procedure. Can J Neurol Sci 2000;27(4):271–3. DOI: 10.1017/s0317167100000974Wijdicks E.F.M. Hemicraniotomy in massive hemispheric stroke: a stark perspective on a radical procedure. Can J Neurol Sci 2000;27(4):271–3. DOI: 10.1017/s0317167100000974Olnhausen O.V., Thoren M., Vogelsang A.V. et al. Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. Acta Neurochir (Wien) 2016;158(5):865–72; discussion 873. DOI: 10.1007/s00701-016-2749-9Olnhausen O.V., Thoren M., Vogelsang A.V. et al. Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction. Acta Neurochir (Wien) 2016;158(5):865–72; discussion 873. DOI: 10.1007/s00701-016-2749-9Simard J.M., Sahuquillo J., Sheth K.N. et al. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011;13(2):217–29. DOI: 10.1007/s11940-010-0110-9Simard J.M., Sahuquillo J., Sheth K.N. et al. Managing malignant cerebral infarction. Curr Treat Options Neurol 2011;13(2):217–29. DOI: 10.1007/s11940-010-0110-9Slezins J., Keris V., Bricis R. et al. Preliminary results of randomized controlled study on decompressive carniectomy in treatment of malignant middle cerebral artery stroke. Medicina (Kaunas) 2012;48(10):521–4. PMID: 23324248.Slezins J., Keris V., Bricis R. et al. Preliminary results of randomized controlled study on decompressive carniectomy in treatment of malignant middle cerebral artery stroke. Medicina (Kaunas) 2012;48(10):521–4. PMID: 23324248.Dasenbrock H.H., Robertson F.C., Aziz-Sultan M.A. et al. Patient age and the outcomes after decompressive hemicraniectomy for stroke: a notionwide inpatient analysis. Neurocrit Care 2016;25(3):371–83. DOI: 10.1007/s12028-016-0287-1Dasenbrock H.H., Robertson F.C., Aziz-Sultan M.A. et al. Patient age and the outcomes after decompressive hemicraniectomy for stroke: a notionwide inpatient analysis. Neurocrit Care 2016;25(3):371–83. DOI: 10.1007/s12028-016-0287-1Van Middelaar T., Richard E., van der Worp H.B. et al. Quality of life after surgical decompression for spaceoccupying middle cerebral artery infarct: a cohort study. BMC Neurol 2015;15:156. DOI: 10.1186/s12883-015-0407-0Van Middelaar T., Richard E., van der Worp H.B. et al. Quality of life after surgical decompression for spaceoccupying middle cerebral artery infarct: a cohort study. BMC Neurol 2015;15:156. DOI: 10.1186/s12883-015-0407-0Lin J., Frontera J.A. Decompressive hemicraniectomy for large hemispheric strokes. Stroke 2021;52(4):1500–1510. PMID: 33719518. DOI: 10.1161/STROKEAHA.120.032359Lin J., Frontera J.A. Decompressive hemicraniectomy for large hemispheric strokes. Stroke 2021;52(4):1500–1510. PMID: 33719518. DOI: 10.1161/STROKEAHA.120.032359Крылов В.В., Никитин А.С., Буров С.А. и др. Декомпрессивная краниотомия в комплексной интенсивной терапии злокачественных форм массивного ишемического инсульта. Журнал неврологии и психиатрии им. С.С. Корсакова 2013;113(1):15–22.Krylov V.V., Nikitin A.S., Burov S.A. et al. Decompressive craniotomy in the complex intensive treatment of malignant forms of massive ischemic stroke. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova = Korsakov’s Journal of Neurology and Psychiatry 2013;113(1)1:15–22. (In Russ.).Vital R., Hamamoto P.T., Braga G.P. et al. Acute stroke management decompressive hemicraniectomy in a South American population: morbitites and outcome analysis focusing on age differences. Int J Stroke 2014;9(Suppl 3):101.Vital R., Hamamoto P.T., Braga G.P. et al. Acute stroke management decompressive hemicraniectomy in a South American population: morbitites and outcome analysis focusing on age differences. Int J Stroke 2014;9(Suppl 3):101.Naidu P.B., Vivek V., Shareef M.H. et al. Decompressive hemicraniectomy in malignant MCA infarct in a tertiary centre. Interdiscip Neurosurg 2021;24(3):101019. DOI: 10.1016/j.inat.2020.101019Naidu P.B., Vivek V., Shareef M.H. et al. Decompressive hemicraniectomy in malignant MCA infarct in a tertiary centre. Interdiscip Neurosurg 2021;24(3):101019. DOI: 10.1016/j.inat.2020.101019Kim D., Ko S., Cha J. et al. Updated Korean clinical practice guidelines on decompressive surgery for malignant middle cerebral artery territory infarction. J Stroke 2015;17(3):369–76. DOI: 10.5853/jos.2015.17.3.369Kim D., Ko S., Cha J. et al. Updated Korean clinical practice guidelines on decompressive surgery for malignant middle cerebral artery territory infarction. J Stroke 2015;17(3):369–76. DOI: 10.5853/jos.2015.17.3.369Yang M.H., Lin H.Y., Fu J. et al. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: a systematic review and metaanalysis. Surgeon 2015;13(4):230–40. DOI: 10.1016/j.surge.2014.12.002Yang M.H., Lin H.Y., Fu J. et al. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: a systematic review and metaanalysis. Surgeon 2015;13(4):230–40. DOI: 10.1016/j.surge.2014.12.002Hofmeijer J., Kappelle L J., Algra A. et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threating Edema Trial (HAMLET): a multicentre, open, randomized trial. Lancet Neurol 2009;8(4):326–33. DOI: 10.1016/S1474-4422(09)70047-XHofmeijer J., Kappelle L J., Algra A. et al. Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threating Edema Trial (HAMLET): a multicentre, open, randomized trial. Lancet Neurol 2009;8(4):326–33. DOI: 10.1016/S1474-4422(09)70047-XКрылов В.В., Древаль О.Н., Джинджихадзе Р.С. и др. Диагностика и лечение злокачественных форм ишемического инсульта в бассейне средней мозговой артерии. Клинические рекомендации. М., 2015. 16 с. Доступно по: https://ruans.org/Text/Guidelines/ischemic_stroke_severe_form_mca.pdfKrylov V.V., Dreval’ O.N., Dzhindzhikhadze R.S. et al. Diagnosis and treatment of malignant forms of ischemic stroke in the middle cerebral artery basin. Clinical recommendations. Moscow, 2015. 16 p. Available at: https://ruans.org/Text/Guidelines/ischemic_stroke_severe_form_mca.pdf (In Russ.).Jüttler E., Schwab S., Schmiedek P. et al. Decompressive surgery for the treatment of malignant infarction of middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke 2007;38(9):2518–25. DOI: 10.1161/STROKEAHA.107.485649Jüttler E., Schwab S., Schmiedek P. et al. Decompressive surgery for the treatment of malignant infarction of middle cerebral artery (DESTINY): a randomized, controlled trial. Stroke 2007;38(9):2518–25. DOI: 10.1161/STROKEAHA.107.485649Jüttler E., Unterberg A., Woitzik J. et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370(12):1091–100. DOI: 10.1056/NEJMoa1311367Jüttler E., Unterberg A., Woitzik J. et al. Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 2014;370(12):1091–100. DOI: 10.1056/NEJMoa1311367Hecht N., Neugebauer H., Fiss I. et al. Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke. J Cereb Blood Flow Metab 2018;38(6):1096– 103. DOI: 10.1177/0271678X17718693Hecht N., Neugebauer H., Fiss I. et al. Infarct volume predicts outcome after decompressive hemicraniectomy for malignant hemispheric stroke. J Cereb Blood Flow Metab 2018;38(6):1096– 103. DOI: 10.1177/0271678X17718693Pilato F., Pellegrino G., Calandrelli R. et al. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: a real-world study. J Neurol Sci 2022;441:120376. DOI: 10.1016/j.jns.2022.120376Pilato F., Pellegrino G., Calandrelli R. et al. Decompressive hemicraniectomy in patients with malignant middle cerebral artery infarction: a real-world study. J Neurol Sci 2022;441:120376. DOI: 10.1016/j.jns.2022.120376Frank J., Schumm P., Wroblewski K. et al. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke 2014;45(3):781–7. DOI: 10.1161/STROKEAHA.113.003200Frank J., Schumm P., Wroblewski K. et al. Hemicraniectomy and durotomy upon deterioration from infarction-related swelling trial: randomized pilot clinical trial. Stroke 2014;45(3):781–7. DOI: 10.1161/STROKEAHA.113.003200Gupta R., Connolly S., Mayer S., Elkind M.S. Hemicraniectomy for massive middle cerebral artery territory infarction. Stroke 2004;35(2):539–43. DOI: 10.1161/01.STR.0000109772.64650.18Gupta R., Connolly S., Mayer S., Elkind M.S. Hemicraniectomy for massive middle cerebral artery territory infarction. Stroke 2004;35(2):539–43. DOI: 10.1161/01.STR.0000109772.64650.18Budhdeo S., Kolias A.G., Clark D.J. et al. A retrospective cohort study to assess patient and physician reported outcome measures after decompressive hemicraniectomy for malignant middle cerebral artery stroke. Cureus 2017;9(5):e1237. DOI: 10.7759/cureus.1237Budhdeo S., Kolias A.G., Clark D.J. et al. A retrospective cohort study to assess patient and physician reported outcome measures after decompressive hemicraniectomy for malignant middle cerebral artery stroke. Cureus 2017;9(5):e1237. DOI: 10.7759/cureus.1237Zweckberger K., Juttler E., Bösel J., Unterberg W.A. Surgical aspects of decompression craniectomy in malignant stroke: review. Cerebrovasc Dis 2014;38(5):313–23. DOI: 10.1159/000365864Zweckberger K., Juttler E., Bösel J., Unterberg W.A. Surgical aspects of decompression craniectomy in malignant stroke: review. Cerebrovasc Dis 2014;38(5):313–23. DOI: 10.1159/000365864Wei H., Jia F.M., Yin H.X., Guo Z.L. Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis. Biosci Rep 2020;40(1):BSR20191448. DOI: 10.1042/BSR20191448Wei H., Jia F.M., Yin H.X., Guo Z.L. Decompressive hemicraniectomy versus medical treatment of malignant middle cerebral artery infarction: a systematic review and meta-analysis. Biosci Rep 2020;40(1):BSR20191448. DOI: 10.1042/BSR20191448Warwick Pexman J.H., Barber P.A., Hill M.D. et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001;22(8):1534–42. PMID: 11559501.Warwick Pexman J.H., Barber P.A., Hill M.D. et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 2001;22(8):1534–42. PMID: 11559501.Sims J.R., Gharai L.R., Schaefer P.W. et al. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology 2009;72(24):2104–10. DOI: 10.1212/WNL.0b013e3181aa5329Sims J.R., Gharai L.R., Schaefer P.W. et al. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology 2009;72(24):2104–10. DOI: 10.1212/WNL.0b013e3181aa5329Luby M., Hong J., Merino J.G. et al. Stroke mismatch volume with the use of ABC/2 is equivalent to planimetric stroke mismatch volume. AJNR Am J Neuroradiol 2013;34(10):1901–7. DOI: 10.3174/ajnr.A3476.Luby M., Hong J., Merino J.G. et al. Stroke mismatch volume with the use of ABC/2 is equivalent to planimetric stroke mismatch volume. AJNR Am J Neuroradiol 2013;34(10):1901–7. DOI: 10.3174/ajnr.A3476.Adams H.P. Jr., Bendixen B.H., Kappelle L.J. et al. Classification of subtype of acute ischemic stoke. Definitions for use in multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stoke 1993;24(1):35–41. DOI: 10.1161/01.str.24.1.35Adams H.P. Jr., Bendixen B.H., Kappelle L.J. et al. Classification of subtype of acute ischemic stoke. Definitions for use in multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stoke 1993;24(1):35–41. DOI: 10.1161/01.str.24.1.35Spilker J., Kongable G., Barch C. et al. Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group. J Neurosci Nurs 1997;29(6):384–92. DOI: 10.1097/01376517-199712000-00008Spilker J., Kongable G., Barch C. et al. Using the NIH Stroke Scale to assess stroke patients. The NINDS rt-PA Stroke Study Group. J Neurosci Nurs 1997;29(6):384–92. DOI: 10.1097/01376517-199712000-00008

The authors declare that there are no conflicts of interest present.