clinmedКлиническая медицинаClinical Medicine (Russian Journal)0023-21492412-1339ООО «Медицинское информационное агентство»10.30629/0023-2149-2023-101-1-41-49clinmed-498Research ArticleОРИГИНАЛЬНЫЕ ИССЛЕДОВАНИЯORIGINAL INVESTIGATIONSНеврологические нарушения у пациентов с тромботической тромбоцитопенической пурпуройNeurological disorders in patients with thrombotic thrombocytopenic purpurahttps://orcid.org/0000-0001-8818-8949ГалстянГ. М.GalstyanG. M.

Галстян Геннадий Мартинович  — д-р мед. наук, заведующий отделом реанимации и интенсивной терапии

125167, Москва

Galstyan Gennady M.

125167, Moscow

gengalst@gmail.comhttps://orcid.org/0000-0002-8141-9422КлебановаЕ. Е.KlebanovaE. E.

Клебанова Елизавета Евгеньевна - врач-анестезиолог-реаниматолог отделения реанимации и интенсивной терапии

125167, Москва

Klebanova Elizaveta E.

125167, Moscow

https://orcid.org/0000-0003-1492-1735МамлееваС. Ю.MamleevaS. Yu.

Мамлеева Светлана Юрьевна — заведующая экспресс-лабораторией отдела реанимации и интенсивной терапии

125167, Москва

Mamleeva Svetlana Yu.

125167, Moscow

https://orcid.org/0000-0002-8239-5442ФедороваС. Ю.FedorovaS. Yu.

Федорова Светлана Юрьевна — врач-невролог лаборатории по изучению психических и неврологических расстройств при заболеваниях системы крови

125167, Москва

Fedorova Svetlana Yu.

125167, Moscow

https://orcid.org/0000-0001-9431-8316ДроковМ. Ю.DrokovM. Yu.

Дроков Михаил Юрьевич — канд. мед. наук, руководитель сектора по изучению иммунных воздействий и осложнений после ТКМ

125167, Москва

Drokov Mikhail Yu.

125167, Moscow

https://orcid.org/0000-0001-5085-4045ЯцыкГ. А.YatsykG. A.

Яцык Галина Александровна — канд. мед. наук, заведующая кабинетом магнитно-резонансной томографии

125167, Москва

Yatsyk Galina A.

125167, Moscow

ФГБУ «Национальный медицинский исследовательский центр гематологии» Минздрава РоссииРоссияNational Medical Research Center of HematologyRussian Federation20232703202310114149Copyright © Галстян Г.М., Клебанова Е.Е., Мамлеева С.Ю., Федорова С.Ю., Дроков М.Ю., Яцык Г.А., 20232023Галстян Г.М., Клебанова Е.Е., Мамлеева С.Ю., Федорова С.Ю., Дроков М.Ю., Яцык Г.А.Galstyan G.M., Klebanova E.E., Mamleeva S.Y., Fedorova S.Y., Drokov M.Y., Yatsyk G.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.clinmedjournal.com/jour/article/view/498

Цель: анализ неврологических нарушений у пациентов с впервые выявленной тромботической тромбоцитопенической пурпурой (ТТП). Материал и методы. В исследование включены обращения врачей, заподозривших ТТП, а также проанализированы данные о проявлениях болезни у 40 пациентов с ТТП. Результаты. Из 208 обращений в связи с подозрением на ТТП и направления образцов плазмы для исследования активности ADAMTS13 неврологи обратились в 2% случаев. Диагноз ТТП подтвержден у 40 пациентов, из них у 31 (77,5%) отмечены неврологические нарушения, у 9 (22,5%) неврологических нарушений не было. Пациенты с неврологическими нарушениями были старше пациентов без неврологических нарушений (медианы 37 лет и 31 год, р = 0,006). Неврологические нарушения реже наблюдались при ТТП, ассоциированной с беременностью (р = 0,008). Среди неврологических симптомов были нарушения речи (40%), головная боль (30%), когнитивный дефицит (32,5%), угнетение сознания (22,5%), парезы (25%), нарушения чувствительности (20,5%), судороги (10%). При магнитной резонансной томографии/компьютерной томографии (МРТ/КТ) выявлены ишемический инсульт у 47,5%, геморрагический инсульт у 15%. У 6 пациентов, несмотря на неврологическую симптоматику, при МРТ/КТ патология не выявлена. У 4 пациентов при отсутствии неврологических симптомов при МРТ/КТ выявлены ишемические очаги в головном мозге. Умерли 8 пациентов: 2 от сепсиса, 6 от ишемического инсульта. У выживших пациентов после достижения ремиссии неврологическая симптоматика регрессировала. Заключение. Неврологические симптомы выявляются у большинства пациентов с ТТП. МРТ/КТ головного мозга необходимо выполнять всем пациентам с ТТП.

Aim: to analyze the first neurological manifestation in patient with thrombotic thrombocytopenic purpura (TTP). Material and methods. The appeals from physicians who suspected TTP were included in the study. The neurological symptoms in 40 patients with TTP were also analyzed. Results. Among 208 physician appeals about the suspicion of TTP and the referral of plasma samples for testing of ADAMTS13 activity, there were 2% of neurologists. The diagnosis of TTP was confirmed in 40 patients. 9 (22.5%) had no neurological symptoms, and 31 (77.5%) had neurological disorders. Patients with neurological symptoms were older than patients without neurological symptoms (median 37 years and 31 years, p = 0.006). Neurological symptoms were less frequently observed in pregnancy-associated TTP (p = 0.008). Among neurological symptoms there were speech disorders (40%), headache (30%), cognitive deficits (32.5%), depression of consciousness (22.5%), paresis (25%), sensation disorders (20.5%), seizures (10%). Magnetic resonance imaging/computed tomography (MRI/CT) revealed ischemic stroke in 47.5%, hemorrhagic stroke in 15%. In 6 patients, despite neurological symptoms, no pathology was detected with MRI/CT. In 4 patients, in the absence of neurological symptoms, MRI/CT revealed ischemic foci in the brain. 8 patients died: 2 patients died from sepsis, 6 - from ischemic stroke. In surviving patients, neurological symptoms regressed after remission. Conclusion. Neurological symptoms are detected in most patients with TTP. Brain MRI/CT should be performed in all patients with TTP

тромботическая тромбоцитопеническая пурпураневрологические симптомымагнитно-резонансная томографиякомпьютерная томографияthrombotic thrombocytopenic purpuraneurological symptomsmagnetic resonance imagingcomputed tomographyReferencesFurlan M., Robles R., Lämmle B., Lammle B., Lämmle B. Partial purifi cation and characterization of a protease from human plasma cleaving von Willebrand factor to fragments produced by in vivo proteolysis. Blood. 1996;87:4223–4234. DOI: 10.1182/blood.v87.10.4223.bloodjournal87104223Furlan M., Robles R., Lämmle B., Lammle B., Lämmle B. Partial purifi cation and characterization of a protease from human plasma cleaving von Willebrand factor to fragments produced by in vivo proteolysis. Blood. 1996;87:4223–4234. DOI: 10.1182/blood.v87.10.4223.bloodjournal87104223Sadler J.E. Pathophysiology of thrombotic thrombocytopenic purpura. Blood. 2017;130:1181–1188. DOI: 10.1182/blood-2017-04-636431Sadler J.E. Pathophysiology of thrombotic thrombocytopenic purpura. Blood. 2017;130:1181–1188. DOI: 10.1182/blood-2017-04-636431Silverstein А. Thrombotic thrombocytopenic purpura. The initial neurologic manifestations. Arch. Neurol. 1968;18:358–362.Silverstein А. Thrombotic thrombocytopenic purpura. The initial neurologic manifestations. Arch. Neurol. 1968;18:358–362.Huang F., Li X.P., Xu, Y., Li X.Y., Li D.R., Hao Y., Yu Z.Q., Jin J., Wang J. Clinical characteristics and outcomes of adult patients with acquired thrombotic thrombocytopenic purpura: A single center retrospective study. Ann. Palliat. Med. 2021;10:5351–5358. DOI: 10.21037/apm-21-759Huang F., Li X.P., Xu, Y., Li X.Y., Li D.R., Hao Y., Yu Z.Q., Jin J., Wang J. Clinical characteristics and outcomes of adult patients with acquired thrombotic thrombocytopenic purpura: A single center retrospective study. Ann. Palliat. Med. 2021;10:5351–5358. DOI: 10.21037/apm-21-759Nokes T., George J.N., Vesely S.K., Awab A. Pulmonary involvement in patients with thrombotic thrombocytopenic purpura. Eur. J. Haematol. 2014;92:156–163. DOI: 10.1111/ejh.12222Nokes T., George J.N., Vesely S.K., Awab A. Pulmonary involvement in patients with thrombotic thrombocytopenic purpura. Eur. J. Haematol. 2014;92:156–163. DOI: 10.1111/ejh.12222Hosler G.A., Cusumano A.M., Hutchins G.M. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are distinct pathologic entities. A review of 56 autopsy cases. Arch. Pathol. Lab. Med. 2003;127:834–839. DOI: 10.5858/2003-127-834-TTPAHUHosler G.A., Cusumano A.M., Hutchins G.M. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome are distinct pathologic entities. A review of 56 autopsy cases. Arch. Pathol. Lab. Med. 2003;127:834–839. DOI: 10.5858/2003-127-834-TTPAHUAmorosi E.L., Ultman J.E. Thrombotic thrombocytopenic purpura: report of 16 cases and review of the literature. Medicine (Baltimore). 1966;45:139–159.Amorosi E.L., Ultman J.E. Thrombotic thrombocytopenic purpura: report of 16 cases and review of the literature. Medicine (Baltimore). 1966;45:139–159.Burrus T.M., Wijdicks E.F., Rabinstein A.A. Brain lesions are most often reversible in acute thrombotic thrombocytopenic purpura. Neurology. 2009;73:66–70. DOI: 10.1212/WNL.0B013E3181AAEA1BBurrus T.M., Wijdicks E.F., Rabinstein A.A. Brain lesions are most often reversible in acute thrombotic thrombocytopenic purpura. Neurology. 2009;73:66–70. DOI: 10.1212/WNL.0B013E3181AAEA1BVendramin C., Thomas M., Westwood J.-P., Scully M. Bethesda assay for detecting inhibitory anti-ADAMTS13 antibodies in immune-mediated thrombotic thrombocytopenic purpura. TH Open. 2018;2:e329–e333. DOI: 10.1055/s-0038-1672187Vendramin C., Thomas M., Westwood J.-P., Scully M. Bethesda assay for detecting inhibitory anti-ADAMTS13 antibodies in immune-mediated thrombotic thrombocytopenic purpura. TH Open. 2018;2:e329–e333. DOI: 10.1055/s-0038-1672187Folstein M.F., Folstein S.E., McHugh P.R. «Mini-mental state» A practical method for grading the cognitive state of patients for the clinicia. J. Psychiatr. Res. 1975;12:189–98. DOI: 10.1016/0022-3956(75)90026-6Folstein M.F., Folstein S.E., McHugh P.R. «Mini-mental state» A practical method for grading the cognitive state of patients for the clinicia. J. Psychiatr. Res. 1975;12:189–98. DOI: 10.1016/0022-3956(75)90026-6Cuker A., Cataland S.R., Coppo P., de la Rubia J., Friedman K.D., George J.N., Knoebl P.N., Kremer Hovinga J.A., Lämmle B., Matsumoto M., Pavenski K., Peyvandi F., Sakai K., Sarode R., Thomas M.R., Tomiyama Y., Veyradier A., Westwood J.P., Scully M. Redefi ning Outcomes in Immune TTP: an International Working Group Consensus Report. Blood. 2021;137(14):1855–61. DOI: 10.1182/blood.2020009150Cuker A., Cataland S.R., Coppo P., de la Rubia J., Friedman K.D., George J.N., Knoebl P.N., Kremer Hovinga J.A., Lämmle B., Matsumoto M., Pavenski K., Peyvandi F., Sakai K., Sarode R., Thomas M.R., Tomiyama Y., Veyradier A., Westwood J.P., Scully M. Redefi ning Outcomes in Immune TTP: an International Working Group Consensus Report. Blood. 2021;137(14):1855–61. DOI: 10.1182/blood.2020009150Benhamou Y., Boelle P.Y., Baudin B., Ederhy S., Gras J., Galicier L., Azoulay E., Provôt F., Maury E., Pène F., Mira J.P., Wynckel A., Presne C., Poullin P., Halimi J.M., Delmas Y., Kanouni T., Seguin A., Mousson C., Servais A., Bordessoule D., Perez P., Hamidou M., Cohen A., Veyradier A., Coppo P. Cardiac troponin-i on diagnosis predicts early death and refractoriness in acquired thrombotic thrombocytopenic purpura. experience of the french thrombotic microangiopathies reference center. J. Thromb. Haemost. 2015;13:293–302. DOI: 10.1111/jth.12790Benhamou Y., Boelle P.Y., Baudin B., Ederhy S., Gras J., Galicier L., Azoulay E., Provôt F., Maury E., Pène F., Mira J.P., Wynckel A., Presne C., Poullin P., Halimi J.M., Delmas Y., Kanouni T., Seguin A., Mousson C., Servais A., Bordessoule D., Perez P., Hamidou M., Cohen A., Veyradier A., Coppo P. Cardiac troponin-i on diagnosis predicts early death and refractoriness in acquired thrombotic thrombocytopenic purpura. experience of the french thrombotic microangiopathies reference center. J. Thromb. Haemost. 2015;13:293–302. DOI: 10.1111/jth.12790Meloni G., Proia A., Antonini G., De Lena C., Guerrisi V., Capria S., Trisolini S.M., Ferrazza G., Sideri G., Mandelli F. Thrombotic thrombocytopenic purpura: prospective neurologic, neuroimaging and neurophysiologic evaluation. Haematologica. 2001;86:1194–1199.Meloni G., Proia A., Antonini G., De Lena C., Guerrisi V., Capria S., Trisolini S.M., Ferrazza G., Sideri G., Mandelli F. Thrombotic thrombocytopenic purpura: prospective neurologic, neuroimaging and neurophysiologic evaluation. Haematologica. 2001;86:1194–1199.Blombery P., Kivivali L., Pepperell D., Mcquilten Z., Engelbrecht S., Polizzotto M.N., Phillips L.E., Wood E., Cohney S. Diagnosis and management of thrombotic thrombocytopenic purpura (TTP) in Australia: Findings from the fi rst 5 years of the Australian TTP/thrombotic microangiopathy registry. Int. Med. J. 2016;46:71–79. DOI: 10.1111/imj.12935Blombery P., Kivivali L., Pepperell D., Mcquilten Z., Engelbrecht S., Polizzotto M.N., Phillips L.E., Wood E., Cohney S. Diagnosis and management of thrombotic thrombocytopenic purpura (TTP) in Australia: Findings from the fi rst 5 years of the Australian TTP/thrombotic microangiopathy registry. Int. Med. J. 2016;46:71–79. DOI: 10.1111/imj.12935Chiasakul T., Cuker A. Clinical and laboratory diagnosis of TTP: an integrated approach. Hematol. Am. Soc. Hematol. Educ. Progr. 2018;530–538. DOI: 10.1182/ASHEDUCATION-2018.1.530Chiasakul T., Cuker A. Clinical and laboratory diagnosis of TTP: an integrated approach. Hematol. Am. Soc. Hematol. Educ. Progr. 2018;530–538. DOI: 10.1182/ASHEDUCATION-2018.1.530Alwan F., Vendramin C., Vanhoorelbeke K., Langley K., McDonald V., Austin S., Clark A., Lester W., Gooding R., Biss T., Dutt T., Cooper N., Chapman O., Cranfi eld T., Douglas K., Watson H.G., van Veen J.J., Sibson K., Thomas W., Manson L., Hill Q.A., Benjamin S., Ellis D., Westwood J.P., Thomas M., Scully M. Presenting ADAMTS13 antibody and antigen levels predict prognosis in immune-mediated thrombotic thrombocytopenic purpura. Blood. 2017;130:466–471. DOI: 10.1182/BLOOD-2016-12-758656Alwan F., Vendramin C., Vanhoorelbeke K., Langley K., McDonald V., Austin S., Clark A., Lester W., Gooding R., Biss T., Dutt T., Cooper N., Chapman O., Cranfi eld T., Douglas K., Watson H.G., van Veen J.J., Sibson K., Thomas W., Manson L., Hill Q.A., Benjamin S., Ellis D., Westwood J.P., Thomas M., Scully M. Presenting ADAMTS13 antibody and antigen levels predict prognosis in immune-mediated thrombotic thrombocytopenic purpura. Blood. 2017;130:466–471. DOI: 10.1182/BLOOD-2016-12-758656Weil E.L., Rabinstein A.A. Neurological manifestations of thrombotic microangiopathy syndromes in adult patients. J. Thromb. Thrombolysis. 2021;51:1163–1169. DOI: 10.1007/s11239-021-02431-5Weil E.L., Rabinstein A.A. Neurological manifestations of thrombotic microangiopathy syndromes in adult patients. J. Thromb. Thrombolysis. 2021;51:1163–1169. DOI: 10.1007/s11239-021-02431-5Berti de Marinis G., Novello S., Ferrari S., Barzon I., Cortella I., Businaro M.A., Fabris F., Lombardi A.M. Correlation between ADAMTS13 activity and neurological impairment in acute thrombotic microangiopathy patients. J. Thromb. Thrombolysis. 2016;42:586–592. DOI: 10.1007/s11239-016-1395-7Berti de Marinis G., Novello S., Ferrari S., Barzon I., Cortella I., Businaro M.A., Fabris F., Lombardi A.M. Correlation between ADAMTS13 activity and neurological impairment in acute thrombotic microangiopathy patients. J. Thromb. Thrombolysis. 2016;42:586–592. DOI: 10.1007/s11239-016-1395-7Bendapud P.K., Hurwitz S., Fry A., Marques M.B., Waldo S.W., Li A., Sun L., Upadhyay V., Hamdan A., Brunner A.M., Gansner J.M., Viswanathan S., Kaufman R.M., Uhl L., Stowel C.P., Dzik W.H., Makar R.S. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol. 2017;4:e157–e164. DOI: 10.1016/S2352-3026(17)30026-1Bendapud P.K., Hurwitz S., Fry A., Marques M.B., Waldo S.W., Li A., Sun L., Upadhyay V., Hamdan A., Brunner A.M., Gansner J.M., Viswanathan S., Kaufman R.M., Uhl L., Stowel C.P., Dzik W.H., Makar R.S. Derivation and external validation of the PLASMIC score for rapid assessment of adults with thrombotic microangiopathies: a cohort study. Lancet Haematol. 2017;4:e157–e164. DOI: 10.1016/S2352-3026(17)30026-1Thiago J., Castro D.S., Rittner L., Appenzeller S., Yamaguti-Hayakawa G.G., Colella M., De P.E.V., Bizzacchi J.M.A., Reis F., Orsi F.A. Association of plasmic score with neurological symptoms in patients with thrombotic thrombocytopenic purpura (TTP). Blood. 2019;5:94–95. DOI: 10.1182/blood-2019-129144Thiago J., Castro D.S., Rittner L., Appenzeller S., Yamaguti-Hayakawa G.G., Colella M., De P.E.V., Bizzacchi J.M.A., Reis F., Orsi F.A. Association of plasmic score with neurological symptoms in patients with thrombotic thrombocytopenic purpura (TTP). Blood. 2019;5:94–95. DOI: 10.1182/blood-2019-129144Souilhol C., Serbanovic-Canic J., Fragiadaki M., Chico T.J., Ridger V., Roddie H., Evans P.C. Endothelial responses to shear stress in atherosclerosis: a novel role for developmental genes. Nat. Rev. Cardiol. 2020;17:52–63. DOI: 10.1038/s41569-019-0239-5Souilhol C., Serbanovic-Canic J., Fragiadaki M., Chico T.J., Ridger V., Roddie H., Evans P.C. Endothelial responses to shear stress in atherosclerosis: a novel role for developmental genes. Nat. Rev. Cardiol. 2020;17:52–63. DOI: 10.1038/s41569-019-0239-5South K., Luken B.M., Crawley J.T.B., Phillips R., Thomas M., Collins R.F., Deforche L., Vanhoorelbeke K., Lane D.A. Conformational activation of ADAMTS13. Proc. Natl. Acad. Sci. USA. 2014;111:18578–18583. DOI: 10.1073/pnas.1411979112South K., Luken B.M., Crawley J.T.B., Phillips R., Thomas M., Collins R.F., Deforche L., Vanhoorelbeke K., Lane D.A. Conformational activation of ADAMTS13. Proc. Natl. Acad. Sci. USA. 2014;111:18578–18583. DOI: 10.1073/pnas.1411979112Luken B.M., Turenhout E.A.M., Hulstein J.J.J., Van Mourik J.A., Fijnheer R., Voorberg J., 2005. The spacer domain of ADAMTS13 contains a major binding site for antibodies in patients with thrombotic thrombocytopenic purpura. Thromb. Haemost. 2005;93:267– 274. DOI: 10.1160/TH04-05-0301Luken B.M., Turenhout E.A.M., Hulstein J.J.J., Van Mourik J.A., Fijnheer R., Voorberg J., 2005. The spacer domain of ADAMTS13 contains a major binding site for antibodies in patients with thrombotic thrombocytopenic purpura. Thromb. Haemost. 2005;93:267– 274. DOI: 10.1160/TH04-05-0301Upreti H., Kasmani J., Dane K., Braunstein E.M., Streiff M.B., Shanbhag S., Moliterno A.R., John Sperati C., Gottesman R.F., Brodsky R.A., Kickler T.S., Chaturvedi S. Reduced ADAMTS13 activity during TTP remission is associated with stroke in TTP survivors. Blood. 2019;134:1037–1045. DOI: 10.1182/blood.2019001056Upreti H., Kasmani J., Dane K., Braunstein E.M., Streiff M.B., Shanbhag S., Moliterno A.R., John Sperati C., Gottesman R.F., Brodsky R.A., Kickler T.S., Chaturvedi S. Reduced ADAMTS13 activity during TTP remission is associated with stroke in TTP survivors. Blood. 2019;134:1037–1045. DOI: 10.1182/blood.2019001056Zhang X.-H., Liang H.-M. Systematic review with network meta-analysis. Diagnostic values of ultrasonography, computed tomography, and magnetic resonance imaging in patients with ischemic stroke. Medicine (Baltimore). 2019;98:e16360. DOI: 10.1097/md.000000000001636Zhang X.-H., Liang H.-M. Systematic review with network meta-analysis. Diagnostic values of ultrasonography, computed tomography, and magnetic resonance imaging in patients with ischemic stroke. Medicine (Baltimore). 2019;98:e16360. DOI: 10.1097/md.000000000001636Mariotte E., Azoulay E., Galicier L., Rondeau E., Zouiti F., Boisseau P., Poullin P., de Maistre E., Provôt F., Delmas Y., Perez P., Benhamou Y., Stepanian A., Coppo P., Veyradier A. Epidemiology and pathophysiology of adulthood-onset thrombotic microangiopathy with severe ADAMTS13 defi ciency (thrombotic thrombocytopenic purpura): A cross-sectional analysis of the French national registry for thrombotic microangiopathy. Lancet Haematol. 2016;3:e237– e245. DOI: 10.1016/S2352-3026(16)30018-7Mariotte E., Azoulay E., Galicier L., Rondeau E., Zouiti F., Boisseau P., Poullin P., de Maistre E., Provôt F., Delmas Y., Perez P., Benhamou Y., Stepanian A., Coppo P., Veyradier A. Epidemiology and pathophysiology of adulthood-onset thrombotic microangiopathy with severe ADAMTS13 defi ciency (thrombotic thrombocytopenic purpura): A cross-sectional analysis of the French national registry for thrombotic microangiopathy. Lancet Haematol. 2016;3:e237– e245. DOI: 10.1016/S2352-3026(16)30018-7Галстян Г.М., Шмаков Р.Г., Клебанова Е.Е., Троицкая В.В., Двирнык В.Н., Сурин В.Л., Пшеничникова О.С., Познякова Ю.М., Полушкина Е.С., Гапонова Т.В., Мамлеева С.Ю., Пырегов А.В., Рогачевский О.В., Сысоева Е.П., Цветаева Н.В. Тромботическая тромбоцитопеническая пурпура у беременных: родоразрешать нельзя прерывать. Где поставить запятую? Гематология и трансфузиология. 2022;67(1):42–61.Galstyan G.M., Shmakov R.G., Klebanova E.E., Troitskaya V.V., Dvirnyk V.N., Surin V.L., Pshenichnikova O.S., Poznyakova Y.M., Polushkina E.S., Gaponova T.V., Mamleeva S.Yu., Pyregov A.V., Rogachevsky O.V., Sysoeva E.P., Tsvetaeva N.V. Thrombotic thrombocytopenic purpura in pregnant women: delivery cannot be interrupted. Where should I put a comma? Hematology and transfusiology. 2022;67(1):42–61. (In Russian). DOI: 10.35754/0234-5730-2022-67-1-42-61Xu, J., Guan, J., Li, Q., Qian, J., Wang, Y., Huang, Y., Chen, B., Yang, Y., 2021. Sudden coma at the onset of severe refractory thrombotic thrombocytopenic purpura with successful treatment. Transfus. Apher. Sci. 2021;60:103225. DOI: 10.1016/j.transci.2021.103225Xu, J., Guan, J., Li, Q., Qian, J., Wang, Y., Huang, Y., Chen, B., Yang, Y., 2021. Sudden coma at the onset of severe refractory thrombotic thrombocytopenic purpura with successful treatment. Transfus. Apher. Sci. 2021;60:103225. DOI: 10.1016/j.transci.2021.103225Aksay E., Kiyan S., Ersel M., Hudaverdi O. Thrombotic thrombocytopenic purpura mimicking acute ischemic stroke. Emerg. Med. J. 2006;23:2–3. DOI: 10.1136/emj.2006.036327.Aksay E., Kiyan S., Ersel M., Hudaverdi O. Thrombotic thrombocytopenic purpura mimicking acute ischemic stroke. Emerg. Med. J. 2006;23:2–3. DOI: 10.1136/emj.2006.036327.Sukumar S., Brodsky M., Hussain S., Cataland S., Chaturvedi S. Cardiovascular disease is a leading cause of death in thrombotic thrombocytopenic purpura (TTP) survivors. Blood. 2020;136:22–23. DOI: 10.1182/blood-2020-138551Sukumar S., Brodsky M., Hussain S., Cataland S., Chaturvedi S. Cardiovascular disease is a leading cause of death in thrombotic thrombocytopenic purpura (TTP) survivors. Blood. 2020;136:22–23. DOI: 10.1182/blood-2020-138551Page E.E., Kremer Hovinga J.A., Terrell D.R., Vesely S.K., George J.N. Thrombotic thrombocytopenic purpura: diagnostic criteria, clinical features, and long-term outcomes from 1995 through 2015. Blood Adv. 2017;1:590–600. DOI: 10.1182/BLOODADVANCES.2017005124Page E.E., Kremer Hovinga J.A., Terrell D.R., Vesely S.K., George J.N. Thrombotic thrombocytopenic purpura: diagnostic criteria, clinical features, and long-term outcomes from 1995 through 2015. Blood Adv. 2017;1:590–600. DOI: 10.1182/BLOODADVANCES.2017005124

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