Ischemic stroke - Causes, symptoms and treatment. MF.

One of the most common cerebrovascular diseases that leads to disability and death is ischemic stroke.
Ischemic stroke - acute impairment of cerebral circulation with damage to brain tissue and its functions due to insufficiency or cessation of blood flow to a specific area of ​​the brain. Ischemic stroke is 85% of all strokes.

There are thromboembolic ischemic stroke, hemodynamic, lacunar.

Thromboembolism is the occlusion of the lumen of the vessel. Thrombosis of cerebral vessels is caused by violations of the structure of the vascular wall - the endothelium, a slowing of blood flow, an increase in the coagulation properties of blood( blood thickening).The source of embolism of cerebral vessels can be decayed atherosclerotic plaques in both cerebral vessels and in the heart vessels of the legs, embolism in fractures( fat), tumors, air, in operations on the neck and chest, with thrombophlebitis. Violation of the heart rate promotes the formation of thrombi and increases the risk of stroke by 5 times.

This is a graphic representation: red blood cells were "stuck together" in a thrombus and blocked the lumen of the vessel. As a result, the blood does not circulate around the vessel and the brain area does not receive nutrition - a stroke develops.

Hemodynamic stroke - develops with prolonged spasm of cerebral vessels, when brain need for nutrients necessary for normal work is not provided. This is possible with high blood pressure and low blood pressure.

Lacunar stroke - develops with lesions of small perforating arteries and does not exceed 15 millimeters in size, manifests itself as a purely motor impairment or sensitive, ataxic.

To the violation of cerebral circulation lead:

- atherosclerosis - systemic vascular disease with the formation of atherosclerotic plaques leading to insufficient blood supply to the brain - hypoxia - ischemia;
- hypertensive disease;
- diseases that cause arterial hypertension( increased blood pressure) - kidney disease - chronic pyelonephritis, glomerulonephritis, urolithiasis;blood, endocrine diseases - diabetes, thyroid disease, high cholesterol);
- vascular dystonia, hypotension;
- heart disease - ischemic disease, arrhythmias, pathology of the heart valves;
- infectious - allergic vasculitis( rheumatic, with systemic lupus erythematosus, syphilis, AIDS, temporal arteritis);
- blood diseases( leukemia, anemia);
- lung diseases - chronic bronchitis, bronchial asthma, emphysema.

The risk of occurrence of an ischemic stroke increases at a combination of an arterial hypertensia with smoking, a diabetes, the raised level of a cholesterin in a blood - excessive use of fat food, stresses, an alcoholism.

As a result of these factors, cerebral ischemia develops( oxygen starvation), metabolism is disrupted. The energy deficit triggers a cascade of complex biochemical reactions( glutamate-calcium cascade), which leads to death( apoptosis) of the brain cells and brain edema. This forms the central( nuclear) zone of the stroke, the zone of necrosis, in which the changes are irreversible. Around it formed a zone of ischemic penumbra( penumbra).This zone is potentially viable. Here the blood flow is lowered, but the energy metabolism is still preserved and the brain structures are not affected. The brain cells( neurons) of this zone are capable of recovery.

Symptoms of a stroke

Everyone should know that when numbness and / or weakness appear in half of the body, the same limbs, severe headache, unsteadiness, dizziness with nausea and vomiting, speech disorders should immediately call an ambulance. With stroke, it is important to provide rapid diagnosis and assistance. For this purpose, an early hospitalization is necessary within 2 hours - 3 days in specialized departments equipped with intensive care units or intensive care units, later in neurological departments.

A 50% stroke develops within the first 90 minutes of the disease, 70 to 80% within 360 minutes. Thus, there is a "therapeutic window" - 2 hours, within which the most effective medical measures for saving neurons of the penumbra zone are possible.

It is therefore very important to seek help as early as possible. This can not only save you from disability, but also save your life.

During the stroke, the following are isolated:

- Acute period;
- acute period - up to 21 days;
- early recovery period - up to 6 months;
- late recovery - up to 2 years;
is a period of persistent consequences.

Diagnosis at stroke

The diagnosis is based on the clinical picture of the disease and neuroimaging of brain damage - computer tomography( which allows early diagnosis of hemorrhagic stroke) and magnetic resonance imaging( the earliest diagnosis of ischemic brain lesions).If tomography is impossible, a lumbar puncture is performed. Blood tests, biochemical analyzes, blood sugar, coagulogram, lipidogram are needed. The patient is examined, except for the neurologist, the therapist, the oculist.

In the photo, neurologists and neurosurgeons of the Hadassah University Medical Center in Jerusalem are seeing brain vessels on the monitor of the newest angiography system.

An image of angiography on a computer monitor. Are shown the sites with the disturbed blood flow partial and complete.

Treatment of stroke

Recognition of the fact that the most common cause of acute ischemic stroke is the thrombus justifies the pathogenetic( ie, aimed at eliminating the mechanisms of the development of the disease) treatment in the acute period - within 2 hours of the development of the disease in the presence of magnetic resonance imaging and excluding hemorrhages -carrying out thrombolysis - restoring the patency of the vessel by "dissolving" the thrombus with injections - activators of plasminogen - actilysis or alteplase,use of anticoagulants.

The faster the patient is taken to the intensive care unit, the better the prognosis for him. Contraindications for carrying out thrombolysis: large dimensions of the focus;CT scans of hemorrhagic stroke, abscess, brain tumors, arteriovenous malformation, aneurysms;severe craniocerebral trauma or stroke after 3 months;systolic pressure more than 185 mm Hg.st., and diastolic more than 110 mm Hg.p.hypocoagulation, bacterial endocarditis.

Undifferentiated stroke treatment includes:

- normalization of the function of external respiration;
- regulation of cardiovascular function;
- correction of blood pressure;
- neuroprotection - semax 1.5% - nasal drops - application at early stages of stroke development significantly reduces neurological defect;Ceraxoi or somazine, cerebrolysin intravenously, glycine rassasyvat in the mouth - protects brain neurons in the penumbra and stimulates their work. And they have to "take over" the functions of the dead in the zone of cell necrosis;
- antioxidants - mildronate, actovegin or solcoseryl, mexidol intravenously;vitamin E.
- vasoactive drugs to improve microcirculation - trental, sermion.

Rehabilitation after a stroke

All patients who underwent a stroke undergo the following stages of rehabilitation: neurological department, neurorehabilitation department, sanatorium treatment, outpatient dispensary supervision.

The main tasks of rehabilitation:

- restoration of disturbed functions;
- mental and social rehabilitation;
- prevention of post-stroke complications.

In accordance with the peculiarities of the course of the disease, the following treatment regimens are consistently used in patients:

- strict bed rest - all active movements are excluded, all movements in bed are performed by medical personnel. But already in this mode rehabilitation begins - turns, wiping - prevention of trophic disorders - bedsores, respiratory gymnastics.
- moderately extended bed regimen - gradual expansion of the patient's motor abilities - independent turnings in bed, active and passive movements, transition to the sitting position. Gradually allowed to eat in the sitting position 1 time a day, then 2 and so on.
- ward mode - with the help of medical personnel or with support( crutches, walkers, stick. ..) you can move within the chamber, perform the available types of self-service( eating, washing, dressing. ..).
- free mode.

The duration of regimens depends on the severity of the stroke and the magnitude of the neurological defect.

Sequelae of stroke

After a stroke, a full regress( recovery) of the neurologic defect is possible and the person remains able to work. Depending on the severity of the neurological manifestations, the ability to work from 3 to 1 groups is possible and a lethal outcome is possible. Therefore, it is important to prevent the development of a stroke.

Prophylaxis of ischemic stroke

Primary prevention of cerebrovascular accidents is the impact on diseases that can lead to a stroke. With arterial hypertension, the constant intake of antihypertensive drugs is important, the stabilization of blood pressure during all 24 hours a day.

Especially often stroke develops in the pre-shorter hours. Dangerous sharp drop in blood pressure. With ischemic disease it is important to normalize the heart rhythm. The use of statins reduces the risk of stroke. Diabetes mellitus affects the survival and severity of neurological symptoms in patients with stroke and increases the risk of developing a second stroke. It is important to take adequate measures to normalize blood sugar levels to correct microvascular complications. Arterial pressure in patients with diabetes should be lower than in people without diabetes.

Persons with the listed diseases should be observed by doctors, consist on the dispensary account at therapists, endocrinologists, rheumatologists, neurologists, annually to be examined, to pass necessary analyzes and the appointed inspections.

Patients who underwent cerebral stroke are subject to follow-up at a neurologist in a polyclinic. On an outpatient stage of rehabilitation, after the end of an acute period of a stroke, prevention of a repeated violation of cerebral circulation is necessary. The neurologist needs to inform the family members of the patient that the risk of a second stroke within the first year is more than 30%.

The program of secondary prevention of stroke provides for three main factors: the normalization of blood pressure, the use of antiaggregants( if necessary - anticoagulants) - aspecard, cardiomagnesium, agrogen, trombone, hypolipidemic drugs - statins - atorvastatin, simvastatin - lymer, simvatin, vabadin, atorvacor,compliance with a diet that excludes the use of cholesterol. In addition, control and correction of blood sugar, lipidogram - the cholesterol content in the blood, as well as heart rhythm disturbances, the treatment of coronary heart disease are necessary.

In conditions of outpatient rehabilitation, it is also necessary to continue medical therapy, physiotherapy exercises, massage, physical therapy, psychotherapy, occupational therapy.

Drug medications are usually administered orally( to drink tablets): nootropic, vasoactive, antioxidant, neurotransmitter, muscle relaxants.

Patients with aphasic disorders show sessions with a speech therapist on the method of speech restoration after a stroke.

Ambulatory rehabilitation should be carried out with the mandatory use of psychocorrection, as the stroke causes psychoemotional disorders in the patient, for example post-depression depression.

In the presence of motor disorders, it is advisable to use occupational therapy and restore domestic skills and self-service.

For the first three years, rehabilitation is most effective and should be done twice a year, including both medications and physiotherapy, myoton, kinesitherapy, massage, physiotherapy exercises, and sanatorium treatment.

The system of step-by-step care for patients with cerebral stroke is a highly effective model allowing timely and qualitative diagnosis, introducing modern pathogenetically valid therapeutic and rehabilitation complexes with differentiated use of different methods and methods, which significantly improves the results of treatment.

Consultation of a neurologist on ischemic stroke

Question: what is TIA ?
Answer: The most favorable type of acute ischemic impairment of cerebral circulation is a transient ischemic attack. Most often this is a severe headache, nausea, possible vomiting, dizziness, unsteadiness in walking, visual and speech disorders, numbness of the extremities. The entire neurologic deficit is restored within a maximum of 24 hours. Patients are subject to hospitalization, examination. After the transferred TIA the patient is on a dispensary record with a neurologist with compulsory treatment of the underlying disease that has disturbed the cerebral blood flow( hypertension, atherosclerosis of the carotid arteries. ..).

Question: is there a prevention of repeated strokes?
Answer: yes. After the ischemic stroke, the patient should constantly take Aspecard( cardiomagnum, agrogenx) - under the control of the blood test - coagulogram, statins( lipipine, simvatin, vabadin. ..) - under the control of lipidograms and dopplerography. Mandatory treatment of the underlying disease - hypertension, cerebral atherosclerosis, rheumatism. ..) All medications are prescribed by a doctor!
In the presence of atherosclerotic stenosis of the carotid arteries, consultation of an angiosurgeon is shown to decide the expediency of surgical treatment.

Question: Do follow a certain diet?
Answer: yes. Reduce your intake of fat. Replace the butter with sunflower, olive. Eat fatty fish, low-fat meat, low-fat dairy products. Limit sweets - cakes, pastries, sweet drinks, ice cream. Avoid alcohol and smoking. Increase in your diet vegetables and fruits.

Question: I have discirculatory zncephalopathy - small ischemic foci when conducting magnetic resonance imaging. Do I need an operation?
Answer: these foci are a sign of discirculatory encephalopathy. You do not need to operate them. It is necessary to treat the underlying disease - vascular drugs, neuroprotectors, with hypertension - hypotensive drugs.

Question: a cyst was formed after a stroke. What to do?
Answer: after a stroke after 1-3 months, a cerebral cyst is formed at the site of brain tissue necrosis, this is the consequence of a stroke. You do not need to operate it.

Doctor neurologist Kobzeva S.V.