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Can xray see blood clot: How is PE Diagnosed? – Blood Clots

by alexxlab

How is PE Diagnosed? – Blood Clots

A number of different things may alert a physician that a person may be experiencing a pulmonary embolism, or blood clot in their lung.  When this is suspected, a number of crucial tests may be performed, including:

Pulse Oximetry

Often, the first test performed when PE is suspected is a blood oxygen level. The simplest way to measure the blood oxygen level is with a pulse oximeter. Pulse oximetry is a noninvasive way (does not involve a blood draw or needle stick) to monitor the percentage of hemoglobin that is saturated with oxygen. Hemoglobin is the unique molecule in red blood cells that has the ability to carry oxygen.

The pulse oximeter consists of a probe or sensor plus a computer. The probe, which looks like a padded clothespin, is placed on a relatively thin part of a person’s body, such as a finger or earlobe. Both red and infrared light are then transmitted through the tissue by the probe. Based on the absorption of the red and infrared light caused by the difference in color between hemoglobin that is saturated with oxygen (red) and unsaturated hemoglobin (blue), the computer can estimate the proportion of hemoglobin that is oxygenated. The pulse oximeter then displays this result as a percentage. A blood oxygen saturation level less than 95 percent is abnormal. It may be explained by a lung or heart problem already present, such as emphysema or pneumonia, or by PE (or both).

Arterial Blood Gas

A more precise measurement of blood oxygen level is obtained from a sample taken directly from an artery with a needle or a thin tube (catheter). An arterial blood gas (ABG) measures the levels of both oxygen and carbon dioxide in the blood to determine how well the lungs are working. While most blood tests are performed on samples taken from a vein, an ABG is performed on a sample taken from an artery. In most cases, the artery in the wrist is used for this purpose, but other arteries may be used. The levels of blood gases are measured as partial pressures in units of millimeters of mercury (mm Hg). A partial pressure of oxygen less than 80 mm Hg is abnormal.

Chest X-Ray

A chest x-ray cannot prove that PE is present or absent because clots do not show up on x-ray. Nevertheless, a chest x-ray is a useful test in the evaluation for PE because it can find other diseases, such as pneumonia or fluid in the lungs, that may explain a person’s symptoms. Occasionally, when pulmonary infarction occurs, the x-ray may suggest this diagnosis, although more testing is necessary to prove it with certainty. A normal or negative chest x-ray with a low, otherwise unexplained blood oxygen level, however, raises the suspicion for PE.

Ventilation-Perfusion Scan (VQ Scan)

A VQ lung scan may be a useful test to determine whether a person has experienced PE. This test evaluates both air flow (V = ventilation) and blood flow (Q = perfusion) in the lungs. About one hour before the test, a slightly radioactive version of the mineral technetium mixed with liquid protein is administered through a vein to identify areas of the lung that may have reduced blood flow. Multiple images are taken from different angles, using a special camera that detects radioactivity. For half of the images, the person breathes from a tube that contains a mixture of air, oxygen, and a slightly radioactive version of the gas xenon, which reveals air flow in different parts of the lung. For the other half of the images, the camera tracks the technetium, which reveals blood flow in different parts of the lung. PE is suspected in areas of the lung that have significant “mismatches”—that is, good air flow but poor blood flow.

Except for the minor discomfort from having an intravenous catheter placed, a VQ lung scan is painless and usually takes less than an hour. The exposure to radioactivity from the test is very minor and results in no side effects or complications.

A radiologist interprets the images from the VQ lung scan and decides whether the probability of a PE is high, low, or intermediate. If the probability is high, the diagnosis is made. If the probability is low or intermediate (that is, nondiagnostic), or if the VQ scan cannot be interpreted clearly, other testing must be considered. Even when PE is ultimately proven to be present, the VQ scan may be nondiagnostic. If clinical suspicion is low and the VQ scan reveals a low probability of PE, generally no further testing is needed. A normal VQ scan means PE is not present.

Spiral Computed Tomography of the Chest

An alternative to the VQ scan is a spiral computed tomography (CT) of the chest. A spiral CT of the chest uses special equipment to obtain multiple cross-sectional x-ray images of the organs and tissues of the chest. CT produces images that are far more detailed than those available with a conventional x-ray. Many different types of tissues—including the lungs, heart, bones, soft tissues, muscles, and blood vessels—can be seen.

When PE is suspected, contrast dye (usually iodine dye) is administered through a vein to make the blood vessels stand out.

During the spiral CT, radiation is emitted from a rotating tube. Different tissues absorb this radiation differently. During each rotation, approximately 1,000 images are recorded, which a computer then reassembles to produce a detailed image of the interior of the chest. The x-ray rotates as the patient passes through the CT scanner in a spiral path—hence the term “spiral” CT. The amount of radiation exposure is relatively low, and the procedure is not invasive.

Pulmonary Angiogram

If the VQ scan interpretation is low, intermediate, or uncertain probability of PE, or if the spiral CT is normal yet the symptoms are still suspicious, then the definitive test is a pulmonary angiogram.  An angiogram is an invasive test that uses x-rays to reveal blockages or other abnormalities within the veins or arteries. Contrast dye (usually iodine dye) helps blood vessels show up clearly on x-rays. During an angiogram, contrast dye is injected into a blood vessel, and its path is tracked by a series of x-rays.

A pulmonary angiogram examines the arteries that carry blood from the heart to the lungs and is performed to see if PE is present. Using x-rays in real-time (fluoroscopy), the radiologist inserts a catheter into a vein and advances it until it reaches the vena cava (the very large vein that carries blood to the heart). Next, the radiologist advances the catheter still farther into the right side of the heart and finally into the pulmonary artery, the large artery that carries blood to the lungs. The radiologist directs the tip of the catheter into the different branches of the right and left pulmonary arteries and injects the contrast dye, which illuminates the arteries on x-ray. If PE is present, it will show up as a blockage.

Risks associated with a pulmonary angiogram include the possibility of damage caused by the catheter, bleeding, and an allergic reaction to the contrast dye. The amount of radiation from the x-rays is too small to cause any harm.

Echocardiogram

An echocardiogram is an ultrasound of the heart. Doppler ultrasound, B-mode ultrasound, and M-mode ultrasound (a rapid sequence of B-mode images that allows motion to be visualized) are combined to give information about the size of the heart, the function of the valves, and the strength of the heart muscle. (Duplex ultrasound is discussed in detail in Question 9. ) The echocardiogram can spot areas of the heart that are not working well. When patients with a PE have an echocardiogram, approximately 40 percent will be found to have abnormalities of the right side of the heart, particularly the right ventricle. While an echocardiogram is not actually used to diagnose a PE, it can identify strain on the right side of the heart caused by a large PE as well as certain heart problems that may imitate a PE.

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Diagnosing Blood Clots | Imaging Tests Overview




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Angiography of thoracic aorta

 

Doppler ultrasonography is the most widely available noninvasive test for deep vein thrombosis.  

Diagnosing deep vein thrombosis and pulmonary embolism may be difficult as the signs and symptoms associated with these disorders are not unique to these conditions. For example, leg pain and swelling or chest pain and shortness of breath may have other causes. As a result, testing is needed to confirm the diagnosis.

Venography and pulmonary angiography remain the gold standards for diagnosis of deep vein thrombosis and pulmonary embolism respectively; however, these tests are now being increasingly replaced by less invasive and less expensive procedures. Three types of imaging tests may be used to diagnose clots in veins.

RADIO LABEL TESTS

Radioactive fibrinogen leg scanning is moderately sensitive and specific for clots in the calf and popliteal veins, but less sensitive for superficial clots in the femoral or iliac veins.

The AcuTect venogram test is a synthetic radiochemical that binds to a protein found on activated platelets. The AcuTect venogram is used to diagnose acute venous clots in the lower extremities of patients with signs and symptoms of such clots. The AcuTect appears to detect acute, but not chronic, clots in the veins.

ULTRASOUND TESTS

The doppler-augmented ultrasound and impedance plethysmography technique are sensitive to proximal clots that cause blockages. Impedance plethysmography does not detect calf vein clots or proximal vein clots that do not block the blood vessel.

Doppler ultrasonography is the most widely available noninvasive test for deep vein thrombosis. Doppler ultrasonography has become the dominant test since the 1980s and has largely replaced impedance plethysmography for noninvasive testing.

X-RAY AND COMPUTED TOMOGRAPHY TESTS

Venography testing can detect clots in both calf and proximal veins.

V/Q scanning may be used as a one-step method to diagnose pulmonary embolism in patients with a normal chest radiograph. In patients with an abnormal chest radiograph, V/Q scanning should be used in combination with helical spiral computed tomography testing. V/Q scans tend to be used mainly to exclude rather than confirm pulmonary embolism. V/Q scanning is able to show small clots–and this ability is enhanced by single photon emission computed tomography.

The helical spiral computed tomography technique is very effective in diagnosing clinically important pulmonary embolism and a large number of alternative diagnoses in patients with symptoms who have undergone a V/Q scan. This is an accurate method for detecting and excluding most types of pulmonary embolism.

Laboratory testing is another method of diagnosis

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Intracardiac thrombi. Diagnosis and treatment

Blood clots can form not only in veins, but also in heart cavities and arteries.

Blood clots are a natural reaction of the body. They contribute to the restoration of damaged blood vessels. A blood clot is a blood clot that contains fibrin (a protein needed for blood clotting). But blood clots in the cavities of the heart is a completely different matter.

The most dangerous thing is that there are no symptoms by which one can suspect the presence of intracardiac thrombi. It is possible to detect a thrombus in the cavities of the heart only during diagnostics (echocardiography, etc.). And any symptoms (shortness of breath or suffocation) a person can only feel with pulmonary embolism.

Thrombi can be in the left or right cavities of the heart, in the atria or ventricles (more often these are parietal thrombi).

What are blood clots:
  • Floating. These are partially attached thrombi. The danger is that the floating part of the thrombus may come off;
  • Parietal, when the clot is completely attached to the wall of the chamber of the heart;
  • Occlusive. The most dangerous! These clots cut off blood flow.

Thrombi in the left side of the heart

Most often, blood clots in the left cavities of the heart occur against the background of three diseases.

People at risk are:
  • with mitral valve stenosis;
  • with atrial fibrillation (atrial fibrillation):
  • with postinfarction aneurysm of the left ventricle.

Blood clots in the left side of the heart – the risk of arterial thromboembolism, ischemic attacks or cerebral infarction! With the localization of blood clots in the left cavities of the heart, the arteries of the kidneys, upper and lower extremities, and the arteries of the intestine can also be affected.

Heart attacks and strokes

In arterial atherosclerosis and plaque rupture, a blood clot forms in the artery. As a result, myocardial infarction (necrosis of the organ tissue) can occur. If a thrombus located in the cavity of the left ventricle breaks off, then, spreading through the blood stream, it can clog the arteries of the brain (as a result, cerebral infarction occurs – ischemic stroke), kidneys (kidney infarction), intestines (intestinal infarction, mesenteric thrombosis), limbs (gangrene).

If a clot breaks off, it can spread with the bloodstream and close the vessel lumen! When the vessel is blocked, blood circulation is disturbed, which leads to oxygen starvation and tissue necrosis. This can cause complications such as myocardial infarction, PE, and even death.

If there is an open oval window in the intercardiac septum, blood clots from the veins of the lower extremities, the pelvis can move from the right atrium to the left and then enter the brain with the blood flow. The result is also a stroke.

Blood clots resulting from an aneurysm of the heart

After a heart attack, parietal thrombi may form in the left ventricle. They are seen by specialists with the help of echocardiography. This is the main type of diagnostic for the detection of blood clots in the cavities of the heart. If they are detected, a specialist may prescribe anticoagulants (in the absence of contraindications).

Thrombi formed during mitral valve stenosis

There is a special variety – a spherical thrombus in the left atrium. Such a thrombus is formed during mitral valve stenosis, in which outflow from the left atrium into the left ventricle is disturbed.

Thrombi formed during atrial fibrillation (atrial fibrillation)

In atrial fibrillation, blood clots are usually localized in the left atrial appendages. The ear is a protrusion of the atrium (it looks like a sac). Thrombi of the left atrial appendage can be detected most often only with transesophageal echocardiography. They are very difficult to detect with echocardiography.

Blood clots in the right side of the heart

The presence of a blood clot in the right side of the heart is fraught with complications in the form of thromboembolism of the branches of the pulmonary artery (a disease in which the arteries of the lungs are affected). PE is one of the most dangerous complications.

A thrombus may first form in the deep veins of the lower extremities. If a floating thrombus breaks off, then with the blood flow it first enters the right heart, and then into the pulmonary artery. This can lead to sudden death!

Diagnosis

The main method for diagnosing intracardiac thrombi in MedicCity is echocardiography.

1

Echo-KG (ultrasound of the heart)

2

Echo-KG (ultrasound of the heart)

3

Echo-KG (ultrasound of the heart)

If you need to diagnose blood clots in the veins, duplex scanning of the veins of the lower extremities is performed, etc.

Treatment

To prevent thrombosis, a specialist may prescribe you anticoagulants or antiaggregants (if there are no contraindications).

Patients with mitral valve stenosis, atrial fibrillation or postinfarction aneurysm need regular echocardiographic monitoring! Especially in the presence of prosthetic valves. In this case, ECHO-KG should be done every year.

After a myocardial infarction, it is necessary to check whether a blood clot has formed in the cavity of the heart.

Those who take hormonal contraception are also at risk. They increase the risk of thrombosis, as well as myocardial infarction. You may find a warning in the instructions for the side effects.

Intracardiac clots can lead to serious complications! If necessary, consult a doctor and follow all recommendations.

The material was prepared with the participation of a specialist:

  • Zakharov Stanislav Yurievich

    Cardiologist, doctor of functional diagnostics

    Highest qualification category, Doctor of Medicine, Member of the European Society of Cardiology and the Russian Society of Cardiology

What does “blood clot break off” mean and why do men have more heart attacks? Interview about blood clots with the Tyumen doctor Artem Gavrilko – June 11, 2020

29-year-old doctor Artem Gavrilko has been working as an X-ray surgeon at OKB No. 1 for more than two years. As a rule, this happens at lightning speed and suddenly. Mortality from diseases of the circulatory system ranks first in the world. But questions still remain: how blood clots appear and why they cause deaths. Artem Gavrilko, a Tyumen X-ray surgeon from OKB No. 1, answered the questions in detail.

— What is a blood clot?

— A blood clot is an intravital blood clot that forms in the human bloodstream, that is, in all vessels. This means that blood clots form in both veins and arteries. In the veins of the lower extremities, for example, blood clots form, but they dissolve thanks to our anti-clotting system. Those mechanisms where the foundations of thrombus formation lie are our defense mechanisms. Each person has a blood clotting system that protects him from bleeding. When a person, for example, damages the skin to stop bleeding, these defense mechanisms begin to work. But in pathological conditions and certain diseases, adaptive defense mechanisms begin to work incorrectly, which contributes to the formation of a blood clot. The thrombus itself can reach several tens of centimeters and be dangerous.

— Where do blood clots most often form?

— If we are talking about the venous system, then in this case, blood clots form in the veins of the lower extremities, that is, in the legs. If we are talking about the arterial system, then here blood clots form in places where there are atherosclerotic plaques. They can be located in the carotid arteries, in the arteries of the lower extremities, in the kidneys. You need to understand that blood clots form from blood and where there is blood.

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— What are the most dangerous places where blood clots form?

– These are veins. Thrombosis in itself is not so dangerous, but it can be unpleasant, can lead to pain and blue legs or both legs. In any case, such manifestations and diseases require treatment. Thrombosis of the lower extremities of the veins is dangerous because a blood clot can migrate from one place along the blood stream to the pulmonary artery and cause a disease called pulmonary embolism. This can lead to death. Why? Because pulmonary embolism has a high mortality rate even with treatment. But this does not mean that if a patient has a diagnosis, then everything will definitely be bad for him.

All such patients are classified as low, medium or high risk. If a person is given a low-risk thromboembolism, then the probability of death in this case is very small – 1.6% by world standards. But if there is a high percentage of thromboembolism, then the risk of death is high and can reach 24.5%. People with such a diagnosis are treated in a surgical hospital.

— How to understand that something is wrong with the body?

— For pulmonary embolism, the main symptom is acute sudden onset of shortness of breath. The patient may be disturbed by coughing, hemoptysis, frequent and sharp pain in the chest. Among other things, thromboembolism may be accompanied by loss of consciousness for a long or short time. These conditions and symptoms require an emergency call for an ambulance. When they appear, in no case should a person himself get to the hospital. He can threaten not only himself, but also everyone around him.

— How are diseases associated with blood clots diagnosed and treated?

— The condition of such a patient is unequivocally assessed by a doctor. Only a specialist prescribes research methods for making a diagnosis – instrumental and laboratory. Laboratory is a D-dimer test, which shows that thrombosis has indeed formed in the body. How does this happen? The patient donates blood, which is taken from him, as for biochemistry. Also, doctors may prescribe a CT scan of the pulmonary artery or angiography (a method of contrast examination of blood vessels) to the patient.

This is how doctors look at the results of the contrast study of blood vessels at the computer

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Thromboembolism is a thrombus that, roughly speaking, “flew” from the veins of the lower extremities into the pulmonary artery. In order to understand whether a person has such a disease or not, you need to see this blood clot. It can be seen under X-ray using contrast. What is it and how does it happen? It is necessary to conduct a special contrast into the vascular bed in order to stain the blood. And the thrombus will not absorb this contrast into itself, it will not be stained. It will be visible on a CT scan and on angiography. In some cases, a thrombus can be seen with echocardiography (ultrasound of the heart).

When examining, the thrombus does not stain, it is visible on the X-ray

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— What is a “clot come off”? Does it immediately lead to the death of a person?

— There is no such term in medicine. The correct term is thromboembolism: the formation of a blood clot in the vascular bed. He really, so to speak, “broke off” and migrated with the blood flow to another place in the vascular bed. This is what patients mean when they say “a blood clot broke off.” In general, the clot itself breaks off and flies away quickly enough.

If, for example, we are talking about pulmonary embolism, then the symptoms of this process develop very, very quickly. But these symptoms may be preceded by thrombosis of the lower extremities. In simple words, in such a patient, the leg swells and becomes very blue. The thrombus in this case has not yet come off and has not flown away, but the risk that this will happen soon is quite large. In such cases, you should immediately consult an emergency doctor, because there is a high risk of death. Similar symptoms can occur within a fairly short time – two days. With the worst course of the disease and the influence of negative factors, a person may die.

Artyom Gavrilko is not from a medical dynasty, his grandfather was a doctor in their family. In his youth, Artem wanted to become either a test pilot or a stuntman, but life led him to medicine to help patients and save lives

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in the veins, it can only be held on a narrow base. Excessive movements, especially active walking, in such a situation can increase blood flow through the veins, and this will provoke a blood clot. In this case, it is best to call an ambulance again. You will most likely be wheeled to the hospital for treatment.

— How fast does a blood clot break off?

– This is about two or three seconds. The fact is that our blood circulates very quickly throughout the body. It is impossible to catch and notice the process of separation of a blood clot. Usually, doctors already see in fact that a thromboembolism has occurred, that is, that a blood clot has flown away and arrived in some place. Tracking how it travels through the body is unrealistic.

This is what the operating room looks like. Remember, the sooner you start treatment, the more chances you have for life

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Who is at risk?

— Patients with lower terminal vein thrombosis and pulmonary embolism should be separated. For patients of the first categories of lower extremity vein thrombosis, there are a lot of risk factors. Major and major surgery or trauma is thought to be a strong predictor of deep vein thrombosis. These are operations, for example, on prosthetics of the femoral joint or knee joint. These patients lie in the postoperative period for a very long time, because they simply cannot move. Therefore, the blood flow in the veins of the lower extremities slows down. This is a favorable moment for the development of thrombosis.

The second category of patients also has several risk factors. These may be people who, for genetic reasons, have a clotting system in favor of thrombosis. Patients with oncology and people who suffer from autoimmune diseases are also at risk. The list of risks also includes childbirth, the postpartum period and taking oral contraceptives. In general, pregnancy is a period when a woman’s body works to the limit. During pregnancy, a woman’s body undergoes a lot of changes. These hormonal changes in a woman’s body create prerequisites for the formation of blood clots in the lower extremities.

— Can blood clots be caused by varicose veins?

— Varicose veins are considered a risk factor for venous thrombosis and thromboembolism. But, of course, not as strong as, for example, a serious operation. Nevertheless, in the European recommendations it appears as a risk, albeit a weak one.

It is correct to say not “varicose veins”, but “chronic venous insufficiency”. Varicose veins are already a stage of chronic venous insufficiency. And there are a lot of them. Yes, chronic venous insufficiency can cause thrombosis and cause pulmonary embolism. How does this happen? In the pathogenesis of the development of venous insufficiency lies an abnormal blood flow through the saphenous veins, they can even be seen on the legs. The first symptoms of chronic venous insufficiency are heaviness in the legs, a feeling of “bursting”, convulsions. The disease is confirmed by ultrasound, doctors see a clear clinical picture. It also needs treatment.

In special protective suits, doctors perform X-ray examinations and operations on patients. One of these weighs more than 10 kilograms, the doctor can spend several hours in it and stay without taking off, from morning to afternoon

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— What is a heart attack and stroke?

– We have previously talked about two categories of patients – those with thrombosis of the veins of the lower extremities, and those with thromboembolism. There is another group – these are patients with thrombosis of the arterial bed. Blood clots form most often in places, I repeat, where there are atherosclerotic plaques. They can be deadly. This is when a thrombus forms on an atherosclerotic plaque on a coronary artery, which then leads to a myocardial infarction. If a blood clot forms in the vessels of the neck, it is a stroke.

This is also a serious illness that can be fatal. If an atherosclerotic plaque (they consist of cholesterol and other compounds of fats, calcium, connective tissue fibers) is located in the arteries of the lower extremities and a blood clot forms on them, then this will already be acute ischemia of the lower extremity. If a person is not provided with timely medical assistance, then he may lose his leg.

— At what age do men and women have heart attacks?

— We have a lot of patients with acute coronary syndrome, they form a thrombus in the coronary vessels, which leads to myocardial infarction. More than a thousand people were operated on last year. This is actually a large group of patients.

The majority of patients with thrombosis are from Tyumen over 40 years of age. However, the doctor notes, now there is a tendency that myocardial infarction is getting younger. This can be facilitated by the quality and standard of living, as well as genetics

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Heart attack tends to increase in frequency with age. Most often these are elderly patients. However, at risk are women over 45 and slightly younger men who are in their forties. Now we see a trend that heart attacks are getting younger every year. In our practice, there have been cases when patients with a heart attack and a coronary thrombus were brought to the hospital at the age of 28. This is facilitated by a lot of negative factors, which reflect genetics, the level and quality of human life.

— Why can men have a heart attack at a younger age?

— Males are more likely to be at risk of heart attack than females. This is a medical fact. In a woman up to about 45 years old (before menopause), there is a protective effect of estrogen. That is, women are protected by their own hormones, which they need to procreate. Men do not have such protection, which is why the stronger sex is more likely to have heart attacks, which occur earlier than women.

— What other risk factors are there?

— And there are also modified risk factors, where one of the main ones is blood pressure. Patients with hypertension are prescribed special drugs, so doctors can influence this factor. Also one of the strict factors in the development of such diseases is smoking. Smokers are more prone to thrombosis, stroke and heart attack. Quitting smoking is a good prevention to prevent serious changes in health.

Diabetes mellitus, malnutrition, when we eat few fruits and vegetables and eat more meat, are also considered risk factors. In general, I want to say that doctors understand that it is very difficult to track a patient’s nutrition, so doctors are guided by simple recommendations for patients to eat more vegetables, where there is useful fiber. It is she who allows you to fill the space in the human body, which will consume less fat and starchy foods.

In the end, I would like to summarize that it is imperative to monitor your health and consult a doctor at the first symptoms of problems in the body. This is the only way to save yourself and prolong your life.

Medical operations in cases of blood clots save the lives of thousands of people.

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Stories with a happy ending, when doctors bring even severe patients back to life, often happen in our region. One such incident occurred this spring. Tyumen doctors saved the life of an 87-year-old man. It all started with the fact that the head of the family came from Novy Urengoy to visit his children in the village of Novotarmansky. In the kitchen, the man suddenly became ill, he lost consciousness. The children immediately called an ambulance, which took the patient to the Regional Clinical Hospital No. 2. After examinations, the patient was diagnosed with an ischemic stroke. A large blood clot blocked the blood flow in the carotid artery and significantly complicated the blood supply to the brain.

Prior to this, the doctors of the Neftyanik Medical Unit rescued 47-year-old Natalia Romanova, who could have had a blood clot. Since school, the woman was worried about varicose veins, after childbirth it worsened: doctors had long recommended surgery. But, like any caring mother, Natalya always had a family in the first place, and there was no time left for herself. The disease bothered her more and more, and the day came when the woman’s health deteriorated sharply.

We also wrote the story of then 15-year-old Alina from Tyumen. One winter, the girl planned to go to a social studies consultation in the morning, but ended up in the hospital. She suffered a massive stroke due to a ruptured aneurysm. Doctors considered the case almost hopeless, but still decided on an operation.