Acute cerebrovascular accident (ACVA) occurs suddenly, but there are situations that can act as triggers, these are:

• high blood pressure;
• cholesterol;
• obesity;
• smoking;
• stress.

What is ischemia?

Cerebral ischemia occurs when there is insufficient blood flow to a certain area of ​​the brain. When there is not enough blood, the nerve cells in this area are deprived of oxygen and nutrients because they are not working in the correct format.

If blood flow is not immediately restored, cells in the affected area begin to die, and this can lead to injury and damage that can trigger related changes.

The extent of these effects will depend on several factors, such as the victim's previous health, the time at which blood flow was cut off, or the area of ​​the brain where the injury occurred.

Risk factors

Cerebral ischemia or stroke usually occurs suddenly. There are people who are more predisposed than others to suffer from it, and it largely depends on their health status and lifestyle. We detail the aspects that need to be taken into account to prevent these dangerous episodes:

• Blood pressure control: Hypertension is the most important risk factor. Having high blood pressure can increase the risk of ischemia or cerebral hemorrhage by up to 5 times.
• Controlling your cholesterol: Helps keep our arteries healthy and therefore prevents stroke. Follow a diet, preferring foods rich in fiber and vitamins, and limiting animal fats.
• Preventing diabetes: This is an important risk factor because it accelerates the aging process of blood vessels, affecting all blood vessels in the body. Try to maintain a healthy weight and limit refined foods.
• Exercise: This protects the arteries of the brain and heart. With 25 minutes of moderate physical activity, you can significantly reduce your risk of suffering from cerebral ischemia.
• No to smoking: Quitting smoking and controlling alcohol consumption should be one of your first priorities to protect yourself from stroke and other cardiovascular diseases.
• Hormonal contraceptives: There are medications that make people more likely to suffer from cerebral ischemia, especially if they are added to other risk factors. Hormones in birth control pills may promote clot formation and therefore increase the likelihood of ischemia. The risk is low, it is better to limit their use in women over 30 years of age who also have hypertension, obesity and bad habits.

Signs

To combat a stroke, the most important thing is to act quickly, because every minute counts. Learning to recognize the symptoms of a stroke is necessary in order to be able to act quickly and thus reduce the consequences of the disease.

You may know what is happening to you, but your condition may remain a mystery to others. When the first signs appear, you must act as soon as possible by notifying emergency services.

Here are some of the symptoms and signs that should alert you.

Lack of strength

We may feel weakness and lack of strength in a leg or arm. This symptom is the most common and can be seen in both limbs and on one side of the body. You may also notice tingling and decreased sensation. Similar sensations can also be noticed on the face.

Asymmetrical smile

It often happens that during a stroke you may see that the mouth is slightly distorted and the person has difficulty smiling. He may have difficulty drinking liquid because it will spill out on one side.

Other signs

If the disease affects the back of the brain (vertebrobasilar region), it may cause double vision and difficulty speaking.

If you feel dizzy, it may be that an ischemic cerebrovascular accident is affecting the area of ​​the brain that controls balance. In this case, you may also notice that you have difficulty coordinating your movements.

Another of the symptoms that should make us suspect that we are facing cerebral ischemia is sudden change in vision. Sometimes it can be double vision, and in other cases it can be a sudden loss. This loss may be complete, although it most often affects only one area of ​​vision. This can happen in one or both eyes.

Sudden difficulty speaking or understanding may also indicate a stroke. If you're having a conversation and suddenly have trouble forming words or composing sentences, it could be a symptom of an illness. Likewise, if you feel like you can't understand words as if they were speaking to you in another language, this could be a sign of vascular disease.

Sudden headache

Feeling a severe headache, a stroke, especially a cerebral hemorrhage, may suddenly appear. However, it is important not to worry because it could also be a headache due to another reason. You should be concerned if the pain is accompanied by some other suspicious symptoms, such as tingling or difficulty moving a body part.

A stroke is a situation in which blood does not reach the brain. This can happen for two different reasons: due to a blood clot, which is something that is blocking the veins or arteries, or due to a rupture in one of these veins through which the blood "moves."

Ischemic stroke, also known as ischemic stroke, occurs when the interruption of blood flow is caused by a clot that blocks a blood vessel in the brain. This is also known as thrombosis or embolism. We talk about thrombosis when a clot or embolus forms in the wall of a cerebral artery, and we talk about embolism when this clot originates elsewhere in the body (such as the heart) and travels through the bloodstream until it reaches the vessels of the brain.

A hemorrhagic stroke, also known as a hemorrhage, occurs when a lack of blood supply to the brain is caused by a ruptured vessel and the subsequent internal hemorrhage it causes.

The onset of symptoms can be very rapid. The main symptoms of cerebral ischemia are:

• blurred vision;
• difficulty controlling muscles;
• speech disorders.

There are two types of cerebral ischemia:

• Focal cerebral ischemia. It occurs when a blood clot occludes a brain vessel, which reduces blood flow to a specific area of ​​the brain, increasing the risk of cell death in that specific area. This may be caused by thrombosis or embolism.
• Global OMNC of the brain. This occurs when blood flow to the brain stops or is significantly reduced. This is often caused by cardiac arrest. If sufficient circulation is restored within a short period of time, symptoms may be temporary.

A person suffering from focal cerebral ischemia will still have some degree of blood flow to part of the brain, however a patient with global ischemia will not have any blood flow to any area of ​​the brain.

Risk factors

Cerebral ischemia can be caused by a variety of diseases and abnormalities, including:

• Vascular abnormalities. Blood vessels can form clots that impede circulation, causing a stroke. They can also rupture or cause vascular malformations, where blood vessels grow abnormally.
• Trauma in the brain. Severe head trauma can also cause ischemia, or rupture, of blood vessels and prevent blood from reaching certain areas of the brain.
• Ventricular tachycardia. It generates a series of irregular heartbeats that can lead to cardiac arrest, cutting off the flow of oxygen completely.
• Plaque deposition in the arteries (atherosclerosis). Even a small buildup of plaque can cause the arteries to narrow, making clots more likely to form.
• Blood clots. Large blood clots can also cause ischemia by blocking blood flow.
• Low blood pressure after a heart attack. Hypotension, in other words, extremely low blood pressure, usually results in insufficient tissue oxygenation.
• Congenital heart defects. People with congenital heart defects may also be prone to developing blood clots.
• Tumors. They cause compression of blood vessels.
• Sickle cell anemia. This can cause cerebral ischemia due to a defect in the blood cells. Cardiac blood cells coagulate more easily than normal blood cells, blocking blood flow to the brain.

Even short-term interruptions in blood supply can cause cerebral ischemia and potentially lead to a situation called ischemic stroke, where brain cells with insufficient blood supply become necrotic and release toxins that damage surrounding cells, causing them to become damaged and release toxins.

Complications

When cerebral ischemia involves areas responsible for regulating functions such as breathing, heart rate and metabolism, it can lead to autonomic manifestations.

Interruption of blood flow to the brain for a few minutes usually results in permanent brain damage. The brain stem cannot recover from severe damage. Mild brain damage may worsen the condition, requiring the use of a ventilator for breathing.

Treatment

If prompt treatment is provided, chances of recovery are possible. Other patients may suffer from brain damage and need therapy to learn certain skills. In some cases, the damage can be reversed with therapy and the patient will have permanent disability.

Prevention

A transient ischemic attack is a brief episode in which blood flow to a vessel in the brain is temporarily stopped. Recognizing and treating a transient ischemic attack when it occurs is important because the patient may be at risk for myocardial paralysis or stroke in the future.

Cerebral ischemia or ischemic stroke occurs when there is a decrease or absence of blood flow to the brain, which reduces the amount of oxygen that reaches the organ and characterizes the picture of cerebral hypoxia. Cerebral hypoxia can lead to complications if not identified and treated as soon as symptoms appear, such as drowsiness, paralysis of the arms and legs, and changes in speech and vision.

Cerebral ischemia can occur at any time during physical activity or even sleep, and is more common in people with diabetes, atherosclerosis, and sickle cell disease. Diagnosis can be made based on imaging tests such as MRI and CT.

There are 2 types of cerebral ischemia:

• In which a clot blocks a blood vessel in the brain and prevents or slows the flow of blood to the brain, which can lead to the death of cells in the area of ​​the brain that has been blocked.
• Where the entire blood supply to the brain is blocked, which can lead to permanent damage to brain tissue if it is not identified and corrected quickly.

Symptoms of cerebral ischemia can last from seconds to longer periods and may be:

• weakness in arms and legs;
• dizziness;
• tingling;
• speech difficulties;
• headache;
• increased blood pressure;
• problems with coordination;
• weakness on one or both sides of the body.

Symptoms of cerebral ischemia should be identified as soon as possible to begin treatment, otherwise permanent brain damage may occur.

In transient cerebral ischemia, symptoms are temporary and last less than 24 hours, but must also be treated clinically.

What is transient cerebral ischemia?

Transient cerebral ischemia, also called a mini-stroke, occurs when there is a short period of reduced blood flow to the brain, usually lasting about 24 hours, and requires immediate care as it may be a sign of more severe cerebral ischemia.

Transient ischemia should be treated according to medical recommendations, usually with vasodilators. Changes in eating and living habits are important, including physical exercise and reducing fat and alcohol intake, as well as avoiding smoking.

Possible consequences of cerebral ischemia

Cerebral ischemia can cause complications such as:

• permanent brain damage;
• paralysis of all or one side of the body;
• loss of coordination;
• difficulty swallowing;
• difficulties with speech;
• emotional problems such as depression;
• vision problems;
• bone fragility;
• weakness or paralysis of an arm, leg, or face.

The effects of cerebral ischemia vary greatly from one person to another and depend on the time taken to begin treatment, and it is often necessary to see a physical therapist, speech therapist or occupational therapist to improve quality of life and prevent complications.

The causes of cerebral ischemia are closely related to a person’s lifestyle. Thus, people suffering from atherosclerosis, diabetes and high blood pressure, which are diseases associated with dietary habits, are at greater risk of cerebral ischemia.

In addition, people who have sickle cell disease are also more likely to suffer from decreased oxygenation of the brain because the altered shape of red blood cells prevents them from carrying oxygen properly.

Coagulation-related problems such as platelet retention and impaired coagulation also contribute to the occurrence of cerebral ischemia since there is a high likelihood of cerebral vascular obstruction.

How is cerebral ischemia treated and prevented?

Treatment of cerebral ischemia is based on the size of the clot and the possible effects on the person, and the use of clot-melting drugs such as Alteplase may be indicated. Treatment should be carried out in a hospital so that blood pressure and intracranial pressure can be controlled while avoiding possible complications.

• nutrition;
• fatty foods should be avoided;
• salt;
• perform physical exercises;
• stop drinking alcoholic beverages;
• stop smoking.

There are some home remedies that can prevent stroke because they have properties that cause the blood to become too thick and form clots.

The terms: ischemic infarction, apoplexy and others mean in different languages ​​the word “stroke”, which is a critical condition with an acute onset, the severity of the stroke depends on the extent of the affected area and the functions controlled by this zone.

A stroke can be an ischemic infarction (white infarction) due to the lack of bleeding and have a thrombotic (25%) and embolic (70%) nature. Red infarction - hemorrhagic stroke (15-20%) - the term is used for intracerebral bleeding, less often subarachnoid or meningeal forms (cerebral aneurysms, severe hypertensive crisis, amyloid angiopathy).

Classification of stroke depending on the affected vascular area:

• Posterior infarction due to pathology of the vertebral arteries.
• Lacunar infarction occurs in a single peripheral and deep artery, affecting the thalamus, internal capsule, or brainstem.

The brain is involved in such vital functions as breathing, metabolic homeostasis, sleep rhythm, swallowing, chewing, eye movements, hearing, maintaining balance, articulation of speech, facial sensitivity in case of illness, certain functions may be impaired.

The trunk is also a kind of crossroads of nerve pathways that regulate movement and its regulation, muscle tone and all the different types of sensitivity, while, as far as vision is concerned, disturbances of the visual field (Mesencephalic region) must be taken into account, but also acute episodes of loss visibility. Often this symptomatology is called “intoxication.”

Deep infarcts affecting the internal capsule give symptoms of contralateral hemiparesis, more or less extensive, with or without tenderness (all or part of the internal capsule).

Lesions of the midbrain cause a significant stroke that affects almost the entire hemisphere, accompanied by contralateral paralysis with loss of speech, motor or sensory aphasia. People do not understand what is being said and appear crazy if the affected hemisphere is dominant, resulting in the inability to see the visual field on one side of the hemiparesis or leading to hemiplegia (strength deficiency).

Strokes caused primarily by vascular pathologies include risk factors that are divided into:

• constant factors: age, gender, race.
• modifiable factors: smoking, alcoholism, obesity, use of oral contraceptives, hypertension and hypertensive heart disease with left ventricular hypertrophy, embolic heart diseases such as heart valve stenosis, bacterial endocarditis, predisposition to deep vein thrombosis, Marfan syndrome, blood viscosity, hypercholesterolemia, diabetes mellitus, coagulation changes, migraine with aura, vasculitis associated with diseases such as lupus, Sjogren's syndrome, arteritis, Cogan's syndrome, etc.

It is clear that primary prevention (that is, measures that must be implemented before the onset of disease) consists of preventing diseases through a lifestyle that leads to avoidance of smoking, alcohol, stress, the use of contraceptives or, if necessary, periodic monitoring of coagulation factors and any thrombotic injury. Inactivity, excess salt, sugar, potatoes, red meat and sausages are unfavorable; preference should be given to river fish, vegetables, and fresh fruits.

Adequate treatment of existing diseases, such as:

• diabetes;
• renal failure;
• hypertension;
• chronic obstructive bronchopathy;
• dental caries;
• recurrent angina;
• tonsillitis.

Diseases such as congenital or acquired heart defects, deep venous insufficiency, blood coagulation defects that may predispose not only to thrombosis but also to bleeding, folic acid deficiency with hyperhomocysteinemia, hemolytic anemia.

Cerebral ischemia is not a simple disease. It is a cardiovascular disease that can occur in two ways.

These are cerebral ischemia, which occurs due to a decrease in blood supply to the brain, and hemorrhagic stroke, which is the entry of blood into the brain tissue due to damage to cerebral vessels.

Cerebral ischemia can be of different types: one of them is when a stroke occurs due to some disease, such as diabetes or problems with uncontrolled hypertension. Here the walls of the cerebral artery are damaged, they begin to become overgrown with platelets, forming what is called a thrombus, and then the so-called thrombosis occurs.

This is a clot in one of the branches of the internal carotid artery, which is located inside the brain. The plaque completely obstructs blood circulation at a certain point. If it persists, this decrease in blood flow results in a heart attack or permanent brain injury.

This obstruction can be caused by a plaque, which is nothing more than a blood clot located at a distance from the damaged artery. It may be at the level of the heart or the great vessels of that organ, and for a moment it becomes detached, travels with the blood, and obstructs the flow of blood to the more distant vessels of the brain.

Another disease that can cause ischemic damage is hypoxia, that is, a decrease in the concentration of oxygen in the blood that reaches the brain, and this may be caused by a decrease in blood pressure or hypotension, which can be secondary to myocardial infarction.

In this case, cardiac output and cerebral circulation may decrease. If this occurs over a long period of time, permanent ischemic brain damage will occur.

Patients with higher risk factors are smokers, as well as those people who have poor eating habits, suffer from cholesterol, triglycerides and patients with heart injuries.

As for the consequences that ischemia can cause, it all depends on the size of the blocked vessel.

A large occluded vessel that has multiple branches can cause a large cerebral infarction. In this case, over time it will lead to long-term disability.

When it comes to small vessels that can be fed by collateral circulation, the consequences will be minimal.

The effects depend on the area of ​​the brain affected. If the disease affects an area that is related to speech, the person may become speechless, if it affects areas such as movement, sensation, hearing, vision, the patient is left with certain dysfunctions, losing the ability to express ideas or understand them.

There are degenerative diseases of the arterial vessels that can accompany childhood pathology, but the disease is most associated in elderly patients.

Manifestations that tend to occur and that are sometimes felt but go unnoticed include, but are not limited to, food intolerances, dizziness, dyspepsia, chest pain and high blood pressure.

Experts say that excess of certain types of food, such as fatty and smoked foods, or habits such as smoking or drinking alcohol, can lead to such a disease.

When there are cases of cerebral ischemia, doctors tend to use general measures aimed at controlling the causes that caused it and which restore the flow of oxygen to the affected tissue. They may also offer surgical treatment in cases of atherosclerotic occlusive disease. However, based on each patient's characteristics, your doctor may recommend certain procedures and tests.

Knowledge of pathophysiological mechanisms allows us to understand neuroimaging changes at different stages of cerebral ischemia and the mechanisms of action on which many therapeutic aspects are based.

The pathophysiology of cerebral ischemia differs in the gray and white matter of the brain. In gray matter, blood vessel obstruction causes ischemic stroke. In the peripheral zone, functional changes in neurons occur, but with the preservation of their structural integrity for some time. The penetration of calcium into cells leads to the launch of a number of biochemical processes that end in the death of neurons. In white matter, loss of energy capacity reverses the direction of ion exchange pumps, resulting in the entry of calcium into tissues. The release of GABA activates specific receptors that protect nerve fibers from the consequences of this phenomenon.

Conclusions. Acute cerebral stroke accompanying ischemia has a dual mechanism: initially it is cytotoxic and then vasogenic. Both factors contribute to increased neurological damage caused by cerebral ischemia.

Cardiovascular diseases are the most common causes of neurological disability. Most vascular lesions of the brain are secondary to atherosclerosis and arterial hypertension.

The main types of brain diseases are:

• Cerebral insufficiency due to transient changes in blood flow.
• Cerebral infarction caused by embolism or thrombosis of intracranial or extracranial arteries.
• Hypertensive parenchymal cerebral and subarachnoid hemorrhage due to congenital aneurysm.
• Arteriovenous malformation, which may cause symptoms due to mass effect, infarction, or hemorrhage.

The neurological signs and symptoms of cerebrovascular disease reflect the area of ​​the brain that is damaged. Ischemic stroke and cerebral hemorrhage tend to occur suddenly, with the hemorrhage usually having a more acute onset.

Ischemic syndrome

According to the latest statistics, in our country there are more than a hundred thousand new cases of the disease per year, as a result of which tens of thousands of people are in need of government assistance.

Stroke is now the leading cause of death among women and the second leading cause of death among men, and is also the leading cause of disability and dementia in adults.

A third of stroke patients develop dementia within the next three months. Specifically, of every three people who suffer a stroke, one is left with a severe disability that leaves them completely dependent on someone else, and the rest, although they do not require ongoing assistance, may suffer the consequences.

This is a problem that appears suddenly and in most cases without previous symptoms, so it is important to control living habits.

The public should be aware of the symptoms of the disease that will prompt them to visit their doctor soon, such as loss of strength, difficulty speaking or understanding, sudden loss of vision, double vision, feeling dizzy or intense and unusual pain in the head.

Etiology: Intracerebral thrombosis or embolism formed from atheroma plaque due to arteritis, valve disease, endocarditis, or atrial fibrillation often causes ischemic arterial occlusion.

Sympathomimetic drugs such as cocaine and amphetamine can cause ischemic strokes.

Vertebral osteophytes can cause compression of the arteries with a risk of cerebral ischemia, and the artery may also have stenosis due to plaque encroachment into the lumen.

Factors that favor the pathology include atherosclerosis, heart disease, diabetes mellitus, and polycythemia.

In both situations, thrombosis or embolism, if deprivation of oxygen and nutrients from the brain continues, triggers a heart attack that can lead to brain damage and neurological injury. They may be permanent.

Westerners' diets high in processed red meat, grains and refined sugars may be associated with an increased risk of cerebral infarction.

People who suffer from migraines with aura are four times more likely to have a stroke or heart disease before age 45. According to recent research, there should be a general predisposition to migraines and heart disease, regardless of risk factors such as alcohol, smoking or oral contraceptive use.

Drinking three or more glasses of alcoholic beverages per day increases the likelihood of cerebral ischemia and embolism by 45%.

More than 20% of the adult population suffers from sleep apnea, and there is an association between these repeated stops of breathing during the night if a cerebral infarction has occurred. In fact, the frequency of apnea is directly proportional to the risk of complications after a cerebral infarction.

Treatment for stroke depends on the cause and type of illness. For cerebral infarction, which is the most common type, medications that prevent blood clotting and facilitate blood circulation are indicated only in selected cases.

Statins have demonstrated their effectiveness in treating myocardial infarction and stroke in patients with diabetes. Patients with diabetes II and receiving atorvastatin have a 48% lower risk of stroke.

Other alternatives aim to kill intra-arterial thrombi with thrombolytic agents that activate tissue plasminogens, such as rt-PA, in the first three hours and in selected cases.

Surgery is limited to very specific situations, such as intervention in the carotid arteries, provided that they exhibit a certain degree of obstruction and that no important sequelae remain.

Any cerebral ischemic process prevents the disappearance of symptoms and neurological signs, varying in their expression depending on the area of ​​the affected brain. To be able to manage the disease, the cause of cerebral ischemia must be known and treatment must be initiated to prevent recurrence of the episode.

If the risk of new episodes of ischemia persists, driving is not recommended.

Patients on anticoagulants should be aware of the increased risk of bleeding from minor impacts and should use caution when driving. It is recommended that the driver not perform forced lateral movements, which reduce cerebral blood flow. Panoramic mirrors are useful for making maneuvers easier.

Cerebral ischemia can occur unexpectedly in men and women. Despite the severity of the disease, it provides treatment and prevention.

Ischemia occurs when there is an interruption or deficiency of blood circulation due to atherosclerosis - thickening and hardening of the arterial wall - or a clot from the heart. In this case, there are difficulties in moving the body and a sudden loss of the ability to speak. Possible weakness of arms and legs. Symptoms appear instantly.

What are the consequences?

It depends on the area of ​​the brain affected. The disease can paralyze one side of the body, impair speech, or affect vision. These effects will be temporary or permanent depending on recovery, i.e. the faster the ischemia disappears, the greater the likelihood of no complications.

Treatment is with medications that dissolve the clot or reduce blockage. However, medications should be taken orally, especially in the first three hours after the problem occurs. After this time, the chances of improvement decrease.

How to prevent the disease?

Controlling blood pressure, diabetes and high blood cholesterol are the main points. Also, by practicing physical exercise, avoiding obesity and following the treatment prescribed by your doctor, you can hope for a favorable prognosis.

Acute cerebral ischemia is a complete or partial decrease in blood flow in a certain area of ​​the brain as a result of a thrombus (blood clot that forms inside an artery or vein) or embolus (solid, liquid or consisting of gaseous bacteria, a fat droplet, an air bubble). An embolus can become lodged in a smaller artery or vein and impede blood circulation.

This reduction in blood flow means that oxygen and glucose do not reach the neurons. This may explain the cognitive and behavioral changes caused by acute cerebral ischemia.

When the blood supply to the brain is interrupted, neurons survive for only three minutes, no more. If this irrigation is not restored, neurons begin to die. Risk factors for this disease primarily occur in the sixth decade of life and include hyperlipidemia (high levels of fats in the blood) and hypertension (high blood pressure).

It has also been observed that frequent consumption of alcohol and tobacco, drug abuse in general and the use of contraceptives can contribute to the formation of blood clots and, as a result, cause acute cerebral ischemic attack.

Additionally, when a person suffers a cardiac infarction, the heart stops pumping enough blood to the brain, resulting in an ischemic process that can lead to cerebral vascular stroke.

As already stated, this disease usually appears at age 60 and, although it is rare in young people, people with obesity, hyperlipidemia and hypertension are susceptible to it.

Several signs or symptoms herald the imminent occurrence of an acute cerebral ischemic attack. The main thing is that a person has problems with speech because he loses control over his speech.

The unexpected presence of a nervous eyelid tic can also be alarming. Disorientation and trembling are possible. The duration of treatment aimed at reducing the damage from acute cerebral ischemic attack is very short: three hours. In fact, the only drug used today in the clinic is prescribed only for those three hours that are considered from the moment of the stroke, because after three hours the drug, instead of helping, can harm the person.

Just three minutes

Acute cerebral ischemia is the third and fifth cause of death in men and women aged 60 years and older. According to global epidemiological studies, most of those who survive are left with walking, speaking, hearing and cognitive problems (that is, attention, thought and memory), depending on the area of ​​the brain that has lost blood supply.

Once the blood supply to the brain is interrupted, neurons survive for only three minutes, no more. If blood flow is not restored, neurons begin to die. It turns out that the prognosis depends on the speed of assistance.

Healthy diet and exercise

After an acute cerebral ischemic attack, some people enter a vegetative state; others cannot walk or move on their own, or speak or write, suffer from dyslexia, or have changes in memory and personality; but others do recover unusually quickly.

The body's response to a cerebral vascular complication is very variable and is related to the area of ​​the affected brain and the general condition of the person.

The severity of acute cerebral ischemic stroke is lower in a person who has followed a healthy, low-fat diet and exercise throughout their life, compared with people who are overweight or obese, have hypertension, and have never exercised.

Video “What is ONMK”

This video explains what acute cerebrovascular accident (ACVA) is, its symptoms and consequences.

And a little about secrets...

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Education: Federal State Budgetary Institution Clinical Hospital, Moscow. Field of activity: general surgery…

One of the main problems in neurology and neurosurgery today is considered to be a violation of the blood supply to the brain of both acute and chronic origin, leading to temporary or persistent negative consequences for the patient. This is due to damage to various brain structures (neurons of the cortex, subcortical and stem formations) due to a deficiency of nutrients and oxygen, which cannot be fully and sufficiently delivered to the area through pathologically altered vessels. One of the most difficult in terms of prognosis for the health and life, treatment and rehabilitation of the patient is acute cerebrovascular accident (usually abbreviated as stroke in medical documentation), in which transient (transient) ischemic attacks develop, and there is also a high risk of ischemic stroke ( heart attack) or hemorrhagic type (hemorrhage).

Causes of stroke

For the development of this pathology, reasons are needed that change the structure and tone of the capillaries, interfering with the full delivery of blood rich in oxygen and nutrients to the brain.
The main risk factors are vascular pathologies (aneurysms, vasculitis, atherosclerosis) or arterial hypertension, especially with a crisis course.

Even before serious problems develop, it is possible to identify minimal manifestations typical of atherosclerotic lesions of veins and arteries. These include sleep disorders and headaches, decreased performance, especially in the evening, periodic dizziness and a feeling of noise in the head. Irritability and nervousness may occur; strong emotionality with sharp transitions from joy to tears; decreased hearing and memory; absent-mindedness; decreased concentration; periodically occurring unpleasant sensations on the skin in the form of tingling, crawling.

Symptoms of neuroses - asthenic, hypochondriacal or depressive - are common.

Dangerous in terms of strokes or transient ischemic attacks are becoming more frequent hypertensive crises, leading to a sharp spasm of blood vessels, a disorder of the water-electrolyte balance and rheological properties of the blood (it thickens, becomes viscous, and flows worse through the capillaries). The listed pathological changes lead to stimulation of the adrenal glands, which increases the release of vasopressor (constricting) factors, which, in turn, contributes to the development of temporary or permanent vascular spasm.

The presence of vascular pathology, disturbing symptoms, and poor health is a serious reason for starting preventive treatment in order to prevent the acute form of the disease.

Acute cerebrovascular accident: development of pathology

To understand what stroke in medicine is, it is important to determine how the brain is supplied with blood and which failures of the circulatory system are the most dangerous. The cervical arteries supply oxygenated and nutrient-rich blood through the foramen magnum into the cranial cavity. The entire organ is densely intertwined with a network of arteries and veins with capillaries extending from them, which allows the neurons to be fully supplied with blood. Each branch of the artery has its own area of ​​responsibility, and through the veins the blood flows from the head, gradually collecting into large vessels.

Both interruptions in the flow of blood through the arteries and failure of the outflow of blood through the veins (so-called stagnation) are dangerous. Typically, acute cerebral circulatory failure occurs in cases where the arteries are damaged and rupture with bleeding or blockage with severe spasm and ischemia of a certain area. Venous problems are more typical for the chronic course of pathological processes due to stagnation of blood in the arteries and veins and a slowdown in the outflow rate.

What is acute stroke with persistent impairments?

At its core, an acute cerebrovascular accident is a sharp discrepancy between the volumes of incoming blood, bringing oxygen and nutrients to the tissues, with the existing needs. Such a dangerous situation arises as a result of persistent ischemia of a certain area of ​​tissue as a result of severe spasm or blockage of the lumen by a thrombus or embolus. Ischemic stroke develops through this mechanism. Another option for interruption of blood circulation, which may result in damage to the brain, is rupture of capillaries with leakage of blood into the tissue, hemorrhage with the formation of a hematoma or an area of ​​hemorrhagic impregnation. Both options refer to persistent circulatory problems.

What is a transient stroke?

As a result of sudden and relatively short-term effects, transient disorders associated with temporary but pronounced vasospasm can develop. If we talk about transient circulatory disorders, what they are can be understood by knowing the basic mechanisms of their formation. This is a temporary spasm of the capillaries in the head, caused by various unfavorable external factors or internal pathological processes, leading to the formation of a certain set of negative symptoms. Neurological manifestations of spasm persist for several minutes or hours to a day, followed by complete restoration of all impaired functions.

Such conditions are classified as pre-stroke; they require special attention from doctors and patients themselves, since without adequate treatment and elimination of all the causes leading to this anomaly, such failures threaten the development of a stroke in the future.

The most common causes of TIA (transient ischemic attack) are the following:

• arterial hypertension with a crisis course, against the background of which sharp spasms occur;
• atherosclerotic damage to the walls of capillaries, leading to a narrowing of their lumen, due to which blood flow to the gray matter of the brain decreases;
• cardiac arrhythmias that impair blood circulation, including the head area;
• heart failure or acute vascular collapse.

It is not difficult to describe transient acute disorders of cerebral circulation and what they are in terms of manifestations. All symptoms can be divided into:

• general cerebral;
• focal.

General cerebral symptoms:

• the appearance of a sharp and severe, painful headache with dizziness, attacks of nausea and vomiting;
• short-term loss of consciousness or a feeling of stupor, disorientation of the patient in space and time are possible.

Focal symptoms:

• the occurrence of temporary paralysis and paresis (partial paralysis of a separate zone), as well as a feeling of crawling (paresthesia);
• visual disturbances with flickering dots, flashes of light or spots;
• various speech disorders;
• problems coordinating when walking or moving limbs;
• non-compliance with the functions of individual nuclei of the cranial nerves (problems with opening the mouth, blinking the eyes, swallowing).

If the diagnosis of a transient circulatory disorder is made immediately, and active professional treatment measures begin to eliminate the spasm, restore normal blood flow, and a competent fight against arrhythmias and hypertension is carried out, then the blood supply is restored, and all negative symptoms disappear within 24 hours without consequences. If such manifestations are ignored or self-medicated, more serious pathological conditions - strokes - can occur.

ACVA, cerebral stroke: what is this diagnosis?

In the presence of persistent circulatory disorders of the brain, long periods of bleeding of certain areas are formed with progressive death of neurons and the formation of an area of ​​tissue necrosis, which forms a cerebral stroke.

If we are talking about a diagnosis of a persistent disorder, what does this mean from a clinical point of view? This is the formation of severe disorders and severe symptoms, up to a coma and death of the patient from increasing respiratory and vascular disorders.

Thus, patients with stroke are people who have experienced a hemorrhagic stroke (hemorrhage due to capillary rupture) or ischemic stroke (irreversible blockage by a thrombus or embolus, persistent irreversible spasm of an atherosclerotic vessel).

Signs

With a hemorrhagic stroke, the symptoms develop acutely, the signs are usually detected against the background of physical or emotional stress in the morning or daytime, loss of consciousness occurs, and the patient may become comatose.

External signs of stroke: the patient’s face turns red, strabismus or eye deviation to the side develops, the face and head turn towards the site of hemorrhage. On the side of the body opposite the hematoma, paralysis of the limb is noted - upper and lower, and pathological reflexes of the tendons and muscles are determined. If the hemorrhage is localized in the area of ​​the stem formations, progressive vascular, cardiac and respiratory disorders and increased blood pressure occur.

Against the background of ischemic stroke, the symptoms develop less acutely, but last longer, gradually the manifestations of the disease increase in strength and severity. Neurological symptoms in this type depend on the location of the feeding artery, the extent of the ischemic zone and the duration of exposure. When a large artery is blocked, a coma is possible with irreversible changes in speech, motor sphere and persistent disorders of the functions of the patient’s internal organs.

Consequences of this pathology

If transient ischemic attacks become more frequent, their duration becomes longer and longer and the causes leading to such cases are not eliminated, strokes and patient disability become the main consequences of stroke. Conditions with deep lesions of consciousness with the early development of cerebral coma have especially unfavorable prognoses. In this case, a real threat to the patient’s life is created, especially against the background of lysis of the blood clot and re-bleeding with worsening harmful consequences.

If the condition after an acute cerebrovascular accident leads to the development of paralysis of the limbs with impairment of the motor sphere, or visual impairments, speech defects, orientation and memory disorders are formed, the patient will need constant medical care and medical assistance.

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Definition of the concept

Vascular diseases of the brain attract the attention of scientists around the world. This is due to their widespread, high mortality, disability of tens of thousands of young and middle-aged people, which makes this problem not only medical, but also social.

In Ukraine, a classification of ONMC has been adopted, according to which the following are distinguished:

1) transient cerebrovascular accident (TCI), transient ischemic attack (TIA);

2) meningeal hemorrhages;

3) stroke (hemorrhagic and ischemic - non-embolic and embolic cerebral infarction);

4) acute hypertensive encephalopathy (AHE).

PNMK- acutely occurring cerebral vascular insufficiency, which is manifested by rapidly passing (according to WHO, within 24 hours) focal or cerebral symptoms or a combination thereof.

PNMK, according to this classification, is divided into transient ischemic attacks (TIA) and PNMK according to the type of hypertensive cerebral crisis. Additionally, PNMK is distinguished by the type of hypertensive crisis (HC with focal neurological symptoms. PNMK is usually the first acute manifestation of vascular pathology of the brain, and in some cases it is a harbinger of a stroke.

Hypertensive crisis- characterized by a sharp rise in blood pressure, which is observed diffusely throughout the brain tissue, and therefore is often accompanied by general cerebral symptoms (headache, nausea, vomiting of central origin, i.e., not bringing relief).

Stroke also called acute cerebrovascular accident, which is accompanied by focal and or cerebral symptoms and lastsmore than 24 hours. As a result of a stroke, symptoms of persistent organic damage to the nervous system appear. There are two main forms of stroke: and.

Causes of the disease

In the etiology of stroke, the leading role belongs to hypertension, symptomatic arterial hypertension, atherosclerosis, or a combination thereof. Less commonly, the cause of stroke is cerebral vasculitis as a manifestation of collagenosis (rheumatism, periarteritis nodosa, systemic lupus erythematosus), specific arteritis, blood diseases, myocardial infarction, congenital heart defects, mitral valve prolapse, etc.

The etiology of ischemic stroke is atherosclerosis, its combination with hypertension, hypertension, cerebral vasculitis with collagenosis, blood diseases (leukemia, erythremia), myocardial infarction, congenital heart defects, etc.

Mechanisms of occurrence and development of the disease (Pathogenesis)

In hypertensive cerebral crises, apparently, the leading role is the disruption of autoregulation of cerebral vessels with the phenomena of excessive cerebral hyperemia, vasodilation, slowing of blood flow, increased permeability of the vascular wall with the development of perivasal edema, and in severe cases, microhemorrhage. The mechanism of vasospasm cannot be excluded. In TIA, one of the important mechanisms is transient ischemia in the area of ​​the atherosclerotic vessel, which occurs during atherosclerotic occlusion or congenital anomaly, as well as in the presence of extracerebral factors (decreased systemic blood pressure, decreased pulse, decreased cardiac output), which occur more often in acute cardiac arrest. vascular insufficiency. Often, PNMK develops as a result of arterio-arterial microembolism, mainly from the main arteries of the head (fragments of a thrombus of an ulcerated atheromatous plaque). As a result of the introduction of computed tomography into the diagnosis of PNMC, it has been established that in a number of cases the development of PNMC is associated with microhemorrhages and microinfarctions.

Clinical picture of the disease (symptoms and syndromes)

PNMK of the HA type develops against a background of high blood pressure, significantly exceeding its normal level in the patient, most often in the daytime and against the background of stressful situations. It is characterized by increasing general cerebral symptoms: headache, which at first can be local in nature (usually in the back of the head), and then becomes diffuse, bursting, pulsating, accompanied by nausea, vomiting, non-systemic dizziness, noise and ringing in the ears, occasionally - disturbances of consciousness (its short-term loss, stunning). In severe cases of PNMK, due to the development of cerebral edema, longer periods of loss of consciousness are possible, up to the development of stupor and superficial coma, convulsive syndrome (usually generalized seizures), and meningeal symptoms. This condition is regarded as OGE. Consequently, PNMK of the HA type is mainly characterized by general cerebral symptoms, and in addition to autonomic symptoms and disorders - hyperemia of the skin of the face, neck, upper chest, hyperhidrosis, tachycardia, etc. Transient neurological deficits are possible: nystagmus, revival and asymmetry of tendon reflexes, inconsistent pathological signs. If PNMK is accompanied by more persistent neurological symptoms - transient dysfunction of the cranial nerves (oculomotor, facial, hypoglossal, etc.), short-term speech disorders, paresis, sensitivity disorders - this indicates in favor of PNMK of the GC type with focal manifestations.

With TIA, the clinical picture of the disease is usually dominated by focal symptoms of damage to the nervous system, which are very diverse and depend on the vascular system. With TIA in the carotid artery, most often there is paresthesia in half of the tongue, in the area of ​​the lips, face, arms, less often in the legs, mono- or hemiparesis, speech impairment in case of damage to the left carotid artery in right-handed people. Less commonly observed are attacks such as Jacksonian epilepsy of the motor or sensory type, and sometimes oculo-pyramidal syndrome (decreased vision on the side of the pathology with contralateral hemiparesis and hemihypesthesia). With TIA in the vertebrobasilar region, systemic dizziness, nystagmus, loss of visual field, diplopia, photopsia and darkening of the eyes, ataxia, dysarthria, weakness in the limbs. TIA in the vertebral-basilar region is observed 2 times more often than in the carotid. In cases where the neurological symptoms of PNMC do not completely regress within 24 hours, the pathology is classified as a “minor stroke”.

The most severe stroke occurs in cases of severe cerebral edema, acute obstructive hydrocephalus, blood breakthrough into the ventricles and subarachnoid space, and secondary hemorrhage into ischemic tissue. As a consequence of these processes, an increase in intracranial pressure develops with brain dislocation and compression of vital formations of the brainstem or compressive ischemia of the cerebral cortex, a sharp decrease in the level of wakefulness and a deepening of neurological deficit with sometimes a prognostically unfavorable outcome, including the development of a persistent vegetative state and brain death.

Cerebral edema is defined as excess accumulation of fluid in the brain tissue, resulting in an increase in brain volume. The more pronounced the cerebral edema, the more severe the stroke. There are three types of cerebral edema: cytotoxic, vasogenic and interstitial (hydrostatic). Cytotoxic edema is caused by a violation of the active transport of sodium ions across the cell membrane, as a result of which sodium freely enters the cell and retains water. This type of edema is characteristic of the early (minutes) stage of cerebral ischemia and is more pronounced in the gray matter than in the white matter. Vasogenic edema is caused by increased permeability of the blood-brain barrier and increased entry of protein macromolecules into the intracellular space. This type of edema is characteristic of the subacute (hours) stage of cerebral catastrophe and can be observed both with heart attacks and with cerebral hemorrhages. Interstitial edema is often caused by acute obstructive hydrocephalus and is usually seen on CT as a “periventricular glow” (see below).

Cerebral edema reaches its peak on the 2-5th day, and then, from the 7th-8th day, if the patient survives this period, it begins to slowly regress. As a rule, the larger the size of the lesion, the more pronounced the edema, although to a certain extent this depends on its location.

Diagnosis of the disease

The diagnosis of stroke is methodologically made in three stages. Initially, stroke is distinguished from other acute conditions associated with brain damage. At the second stage, the nature of the stroke itself is determined - ischemic or hemorrhagic. In conclusion, the localization of hemorrhage and its possible mechanisms of development in hemorrhagic stroke or the basin of the affected vessel and the pathogenesis of cerebral infarction in ischemic stroke are clarified.

Stage I

Diagnosing a stroke as such rarely causes significant difficulties for doctors. The main role in this case is played by the anamnesis collected from the words of relatives, others or the patient himself. Sudden and acute, within a few seconds or minutes, development of persistent neurological deficit in the form of motor, sensory and often speech disorders in persons, usually over 45 years of age, against the background of significant emotional, physical stress, immediately after sleep or taking a hot bath, with high or low blood pressure allows you to accurately diagnose acute cerebrovascular accident. Additional information about the presence of any vascular diseases in the patient (recent myocardial infarction, atrial fibrillation, atherosclerosis of the lower extremity vessels, etc.) or risk factors makes the initial diagnosis more reliable.

The most common misdiagnosis of stroke is made during epileptic seizures (correct diagnosis is helped by a thorough history, EEG, and CT scan of the brain); brain tumors (a gradual increase in the clinical picture after the appearance of the first neurological symptoms, CT scan with contrast; it should be borne in mind that the development of hemorrhage into the tumor or infarction in the tumor area is often possible - conditions that can only be confidently diagnosed using X-ray and radiological methods); arteriovenous malformations (sometimes a history of epileptic seizures, cranial noise, hemorrhagic telangiectasia, CT or MRI, cerebral angiography); chronic subdural hematomas (head injury in recent weeks, severe constant headache, progressive increase in symptoms, use of anticoagulants, hemorrhagic diathesis, alcohol abuse), as well as in hypoglycemic conditions, hepatic encephalopathy, etc.

Stage II

The most difficult and responsible task is to accurately and quickly diagnose the nature of a stroke, since in the acute period of the disease it is these moments that largely determine further treatment tactics, including surgical ones, and, consequently, the prognosis for the patient. It should be emphasized that an absolutely accurate diagnosis of the nature of a stroke - hemorrhage or cerebral infarction - only on the basis of clinical data is hardly possible. On average, in every 4-5th patient, the clinical diagnosis of stroke, made even by an experienced doctor, turns out to be erroneous, which is equally true for both hemorrhage and cerebral infarction. Therefore, along with clinical data, it is highly desirable to carry out a priority CT scan of the brain, since the timeliness and effectiveness of the assistance provided largely depends on this. In general, CT scans of the brain are the international standard for diagnosing stroke.

The accuracy of diagnosing hemorrhages with CT reaches almost 100%. In the absence of evidence of hemorrhage on CT and the presence of appropriate clinical and anamnestic data indicating an acute ischemic cerebrovascular accident, the diagnosis of cerebral infarction can be made with great accuracy even in the absence of any changes in the density of the brain substance on tomograms, which is often observed in the first hours after the development of a stroke. In approximately 80% of cases, a brain CT scan detects an area of ​​low density, clinically corresponding to a cerebral infarction, within the first day after the onset of the disease.

Magnetic resonance imaging is more sensitive than CT in the early hours of cerebral infarction and almost always detects changes in brain matter not visible on conventional CT, as well as changes in the brain stem. However, MRI is less informative for cerebral hemorrhages. Therefore, CT is still widely used even in the most well-equipped neurological clinics in the world dealing with acute cerebrovascular pathology.

Stage III

The localization of hemorrhage or infarction in the brain is important in terms of both emergency medical and surgical procedures, and is also important for predicting the further course of the disease. The role of CT here is also difficult to overestimate. As for the mechanisms of development of acute cerebrovascular accidents, they are, of course, of great importance for the correct choice of treatment tactics for a patient from the very first days of a stroke, but in approximately 40% of cases it is not possible to accurately establish the pathogenesis of a stroke, despite a carefully worked out history and clinical picture development of the disease and the full power of modern instrumental and biochemical research methods. First of all, this concerns cerebral infarction, where the desire to determine its subtype (atherothrombotic, cardioembolic, lacunar, etc.) already in the acute period is necessary, since the choice of therapy depends on this (thrombolysis, regulation of general hemodynamics, treatment of atrial fibrillation, etc.). d.). This is also important for preventing early recurrent episodes of heart attacks.

Treatment of the disease

Approach to patients with acute stroke. Organizational matters

Patients with acute stroke should be hospitalized as quickly as possible. The direct dependence of the prognosis of stroke on the time of initiation of its treatment has been clearly proven. The timing of hospitalization in the first 1-3 hours after the onset of the disease is optimal, although reasonable treatment is also effective in a later period. The optimal option is to hospitalize patients in a multidisciplinary hospital with modern diagnostic equipment, including computed tomography or MRI scanners and angiography, which also has an angioneurological department with an intensive care unit and an intensive care unit with a specially designated unit (beds) and trained personnel to manage these patients. An indispensable condition is also the presence of a neurosurgical department or a team of neurosurgeons in the hospital, since about a third of patients need consultation or provision of this type of specialized care. Staying in such clinics significantly improves the outcomes of acute cerebrovascular accidents and the effectiveness of subsequent rehabilitation.

An altered level of wakefulness (from stupor to coma), increasing symptoms indicating signs of brainstem herniation, as well as severe disturbances in vital functions require hospitalization of the patient in the intensive care unit (ICU). It is advisable to stay in the same departments for stroke patients with severe disturbances of homeostasis, decompensated cardiopulmonary, renal and endocrine pathologies.

Emergency measures upon admission

The examination of the patient upon admission to the emergency room should begin with an assessment of the adequacy of oxygenation, blood pressure levels, and the presence or absence of seizures. Providing oxygenation, if necessary, is carried out by installing an airway and clearing the respiratory tract, and, if indicated, by transferring the patient to mechanical ventilation. Indications for starting mechanical ventilation are: PaO2 - 55 mm Hg. and lower, vital capacity less than 12 ml/kg body weight, as well as clinical criteria - tachypnea 35-40 per minute, increasing cyanosis, arterial dystonia. It is not customary to reduce blood pressure if it does not exceed 180-190 mm Hg. for systolic and 100-110 mm Hg. for diastolic pressure, since in stroke autoregulation of cerebral blood flow is disrupted and cerebral perfusion pressure often directly depends on the level of systemic blood pressure. Antihypertensive therapy is carried out with caution with small doses of beta-blockers (obzidan, atenolol, etc.) or angiotensin-converting enzyme blockers (Renitec, etc.), which do not cause significant changes in the autoregulation of cerebral blood flow. In this case, blood pressure is reduced by approximately 15-20% of the initial values.

With cortical-subcortical lesions and blood breakthrough into the ventricular system, seizures are often observed. Stopping them is also necessary before the start of a neurological examination, since they severely deplete the neurons of the brain. For this purpose, Relanium is used, administered intravenously. In severe cases, sodium thiopental is used. Further, in such patients it is necessary to immediately begin prophylactic administration of long-acting anticonvulsants (finlepsin, etc.).

A neurological examination of the patient upon admission should be brief and include an assessment of the level of wakefulness (Glasgow Coma Scale), the condition of the pupils and oculomotor nerves, motor and, if possible, sensitive areas, speech. Immediately after the examination, a CT scan of the brain is performed. Due to the fact that determining the nature of a stroke is often crucial for further differentiated treatment, including surgery, patients with stroke are recommended to be hospitalized in clinics that have the necessary diagnostic equipment.

After the CT scan, the required minimum of diagnostic tests is performed: ECG, blood glucose level, plasma electrolytes (K, Na, etc.), blood gases, osmolarity, hematocrit level, fibrinogen, activated partial thromboplastin time, urea and creatinine levels, general blood test with platelet count, chest x-ray.

If signs of hemorrhage in the brain are detected on CT and an assessment of its volume and localization is carried out, the question of the advisability of surgical intervention is discussed together with neurosurgeons. For ischemic strokes, it is recommended to perform panarteriography of the main arteries of the head or arteriography on the side of the brain lesion (if blockage of the vessel is suspected). Detection of occlusion of the arteries supplying the brain requires resolving the issue of thrombolytic therapy. Detection of blood in the subarachnoid space on CT often indicates the possibility of subarachnoid hemorrhage. In these cases, the possibility of angiography should be discussed to determine the location and size of the aneurysm and decide on surgery. In doubtful cases, a lumbar puncture may be performed. It is optimal to carry out all of these activities immediately in the emergency room and X-ray department of the clinic.

Conservative treatment

Treatment of patients in the acute period of stroke (approximately the first three weeks) consists of general measures for the treatment and prevention of various types of somatic complications, usually developing against the background of acute cerebrovascular accidents (ACVA), as well as specific methods of treating the stroke itself, depending on its nature .

General measures: maintaining an optimal level of oxygenation, blood pressure, monitoring and correction of cardiac activity, constant monitoring of the main parameters of homeostasis, swallowing (in the presence of dysphagia, a nasogastric tube is placed to prevent aspiration bronchopneumonia and ensure adequate nutrition of the patient), monitoring the condition of the bladder, intestines, skin care. From the very first hours, passive gymnastics and massage of the arms and legs are necessary as an indispensable and most effective condition for the prevention of one of the main causes of mortality in strokes - pulmonary embolism (PE), as well as bedsores and early post-stroke contractures.

Daily care for seriously ill patients should include: turning from side to side every 2 hours; every 8 hours, wiping the patient’s body with camphor alcohol; enemas (at least every other day); administering fluid to the patient at the rate of 30-35 ml per kg of body weight per day; every 4-6 hours, toilet the oropharynx and nasopharynx using suction, followed by rinsing with a warm infusion of 5% chamomile solution or its substitutes. Antibacterial therapy, if necessary, with mandatory intake of adequate doses of antifungal drugs. If signs of DIC appear, administer low-molecular-weight heparin in doses of 7500 IU 2-3 times a day subcutaneously. When transferring a patient to mechanical ventilation, carry out in full the measures described in detail in the manuals on resuscitation and neuroreanimatology.

Currently, hyperventilation and osmotic diuretics are most widely used to treat cerebral edema. Hyperventilation (reducing PaCO2 to a level of 26-27 mm Hg) is the fastest and most effective method of reducing intracranial pressure, but its effect is short-lived and lasts about 2-3 hours. Among the osmotic diuretics, mannitol is most often used. The drug is recommended to be administered intravenously at an initial dose of 0.5-1.5 g/kg body weight over 20 minutes, and then at a dose of half the original every 4-5 hours at the same rate depending on the clinical situation and with taking into account the level of plasma osmolarity. It should be taken into account that exceeding the level of osmolarity above 320 mOsm/L, as well as long-term use of mannitol, is dangerous, since this leads to electrolyte changes, renal pathology and other disorders, which is extremely unfavorable prognostically for the patient. The administration of mannitol in this mode can last no more than 3-4 days. In the absence of mannitol, it is possible to use glycerin in the same dosages orally every 4-6 hours. Corticosteroids and barbiturates have not been shown to be effective in the treatment of cerebral edema in stroke, although their cytoprotective effect is debated.

Acute obstructive hydrocephalus (AOH) is based on severe extraventricular compression of the cerebrospinal fluid ducts or their blockage by blood clots (intraventricular occlusion). This condition, which can be diagnosed only by CT data, develops most often in the first two days with subtentorial and almost one third of supratentorial hemorrhages, as well as with cerebellar infarctions exceeding a third of its hemisphere. With subtentorial lesions, tomography reveals compression of the IV ventricle, a sharp increase in the III and lateral ventricles, with supratentorial lesions - compression of the III and homolateral lateral ventricle or filling them with blood clots with a significant increase in the contralateral lateral ventricle. An increase in OG leads to an increase in brain volume, an increase in intracranial pressure and a deepening of the dislocation of brain structures, including its stem. This, in turn, causes a sharp disruption of liquor outflow and an increase in the difference in pressure between the supra- and subtentorial space, which further increases the displacement and deformation of the trunk. The brain substance is saturated with cerebrospinal fluid from the dilated ventricles. A CT scan reveals the already mentioned x-ray phenomenon - “periventricular glow” - a zone of reduced density in the white matter of the brain around the expanded part of the ventricular system.

The optimal methods for treating AOG are drainage of the lateral ventricles, decompression of the posterior cranial fossa, removal of the hematoma (for hemorrhagic stroke) or necrotic cerebellar tissue (for ischemic stroke). All of them are essentially life-saving operations. The use of decongestant therapy alone in these situations does not have the desired effect.

Blood breakthrough into the ventricular system and subarachnoid space has previously always been considered a poor prognostic, often fatal sign of hemorrhagic stroke. It has now been shown that in more than a third of cases of cerebral hemorrhages, the breakthrough of blood into the ventricles does not lead to death, even if it occurs in the third and fourth ventricles. Blood enters the ventricles from a certain “threshold” volume of the hematoma, characteristic of its particular location. The closer to the midline of the hemispheres the hemorrhage is located, the higher the risk of blood entering the ventricles of the brain and vice versa. The combination of blood breakthrough into the ventricular system and subarachnoid space is observed very often in patients with hemorrhagic stroke. This is usually observed when hematoma volumes exceed 30-40 cm3. There are no reliably proven effective treatments for this complication yet.

Secondary hemorrhage into necrotic tissue is usually observed on days 1-10 with extensive, large and medium-sized cerebral infarctions. Like the previous two complications, it is reliably established based on CT data. Detection of hemorrhagic transformation is possible only with repeated x-ray examinations. This is often a consequence of uncontrolled blood pressure and reperfusion (mainly thrombolytic) therapy, sometimes carried out without taking into account contraindications to it.

Specific treatments for stroke

Hemorrhagic stroke

In every second case, the cause of intracerebral non-traumatic hemorrhage is arterial hypertension, about 10-12% are due to cerebral amyloid angiopathy, about 10% are due to the use of anticoagulants, 8% are due to tumors, and all other causes account for about 20%. Pathogenetically, intracerebral hemorrhages can develop either as a result of vessel rupture or through diapedesis, usually against the background of previous arterial hypertension.

There are currently no specific drug treatments for hemorrhagic stroke; antihypoxants and antioxidants are used. The basis of treatment is general measures to maintain homeostasis and correct major complications (see above). Epsilon-aminocaproic acid is not indicated, since its hemostatic effect does not reach its target, while the risk of pulmonary embolism increases. An important and often decisive method of treating hemorrhagic stroke is surgical intervention - removal of the hematoma using an open or stereotactic method, taking into account its volume, location and impact on brain structures.

Ischemic stroke

Treatment of ischemic stroke is much more difficult than hemorrhagic stroke. First of all, this is due to the diversity (heterogeneity) of the pathogenetic mechanisms underlying it. Based on the mechanism of their development, cerebral infarctions are divided into atherothrombotic, cardioembolic, hemodynamic, lacunar, hemorheological and others. Different subtypes of ischemic strokes differ from each other in frequency, causes, clinical picture of development, prognosis and, of course, treatment.

The basis of cerebral infarctions is developing ischemia associated with complex cascades of interaction between blood components, endothelium, neurons, glia and extracellular spaces of the brain. The depth of such interactions gives rise to varying degrees of trauma to brain structures and, accordingly, the degree of neurological deficit, and their duration determines the time limits for adequate therapy, that is, the “window of therapeutic opportunity.” It follows from this that drugs that differ in their mechanisms and points of application also have different time limits for their effect on the affected areas of the brain.

The basis of specific therapy for ischemic stroke is two strategic directions: reperfusion and neuronal protection, aimed at protecting poorly functioning or almost non-functioning, but still viable neurons located around the infarction site (the “ischemic penumbra” zone).

Reperfusion is possible through thrombolysis, vasodilation, increasing perfusion pressure and improving the rheological properties of blood.

Thrombolytic therapy

The main cerebral thrombolytics are urokinase, streptokinase and their derivatives, as well as tissue plasminogen activator (tPA). All of them act directly or indirectly as plasminogen activators. Currently, the effectiveness of the use of thrombolytics, in particular tPA, has been reliably proven, but it is recommended only after CT and angiography, no later than the first 3 hours (!) from the onset of stroke at a dose of 0.9 mg/kg body weight intravenously, for small lesions on CT and blood pressure not higher than 190/100 mm Hg, no history of strokes, peptic ulcers, etc. Thrombolytic therapy, as a rule, does not eliminate the original causes that caused blockage of blood vessels, since residual atherostenosis remains, but restores blood flow. Hemorrhagic complications when using various thrombolytics, according to various sources, range from 0.7 to 56% (!), which depends on the time of administration and properties of the drug, the size of the infarction, and compliance with the entire range of contraindications to this type of drug therapy.

Vasodilators

The clinical use of vasodilators usually does not give positive results, perhaps because these drugs increase intracranial pressure, reduce mean blood pressure and have a shunting effect, diverting blood from the ischemic zone. Their real role in the development of collateral blood supply to the ischemic focus is still being studied (this applies primarily to aminophylline, the positive effect of which is often noted in clinical practice).

Increasing cerebral perfusion pressure and improving the rheological properties of blood

One of the most well-known methods used for this purpose is hemodilution. It is based on two principles of influencing the microcirculation of the ischemic brain: reducing blood viscosity and optimizing circulatory volume. It is advisable to carry out hypervolemic hemodilution with low molecular weight dextrans (reopolyglucin, rheomacrodex, etc.) only if the patient’s hematocrit level exceeds 40 units, in volumes that ensure its reduction to 33-35 units. In this case, in persons with severe cardiac and/or renal pathology, the state of central hemodynamics should be monitored to prevent the development of pulmonary edema, as well as the level of creatinine, urea and glucose in the blood. The administration of rheopolyglucin for the purpose of correcting hematocrit for more than 7-8 days starting from the moment of stroke development, except in special cases, is not justified. If the effectiveness of the hemodilution method has been proven in approximately half of the international multicenter controlled studies, then the feasibility of other drugs used for these purposes is still the subject of intensive research.

Antiplatelet agents

Aspirin is an effective proven treatment during the acute period of cerebral infarction. It can be used in two modes - 150-300 mg or in small doses of 1 mg/kg body weight daily. There is virtually no risk of hemorrhage. However, very often aspirin cannot be used in patients with gastrointestinal problems. In these cases, its special dosage forms are used (thrombotic ACC, etc.). The feasibility of using antiplatelet agents of other effects, including ticlopidine and dipyridamole (Curantyl), in the acute period, is still being studied, as is the effect of pentoxifylline (Trental).

Direct anticoagulants

There is still no clear evidence for the widespread use of anticoagulants in acute stroke, even in patients with atrial fibrillation. Anticoagulant therapy does not have a direct connection with a reduction in mortality and disability in patients. At the same time, there is strong evidence that heparin (low molecular weight heparin) does prevent deep venous thrombosis and, therefore, the risk of pulmonary embolism (see above).

Neuroprotection

This is the second strategic direction in the treatment of ischemic strokes. Severe metabolic disorders, rapid depolarization of membranes, uncontrolled release of excitatory amino acids and neurotransmitters, free radicals, development of acidosis, sudden entry of calcium into cells, changes in gene expression - this is not a complete list of points of application for neuroprotective drugs in conditions of cerebral ischemia.

Currently, there is a whole range of drugs that have neuroprotective properties: postsynaptic glutamate antagonists; presynaptic glutamate inhibitors (lubeluzole); calcium channel blockers, antioxidants (emoxypine, L-tocopherol); nootropics (piracetam, cerebrolyzin) and others. The feasibility of their use has been proven under experimental conditions. There is still no clear clinical evidence of effectiveness for the vast majority of neuroprotective drugs. In cases where some authors do manage to obtain positive results from their studies, they are almost always questioned by others who conduct their clinical trials to approximately the same standards. In this regard, the validity of their use in patients is not entirely clear. In general, the high promise of neuroprotection as a treatment method is beyond doubt. Its widespread implementation is certainly a matter of the near future.

Prevention of recurrent cerebrovascular accidents

Due to the wide variety of causes underlying strokes, it is necessary, already in the first days of the disease, along with the mentioned treatment methods, to take measures aimed at preventing relapses of stroke.

For cardioembolic strokes due to atrial fibrillation, indirect anticoagulants are recommended. If there are contraindications to their use, it is recommended to use aspirin. The optimal timing for initiating anticoagulant therapy after an acute episode is still unclear. It is believed that to reduce the risk of cerebral hemorrhage, initial treatment should begin with aspirin and continue until the underlying deficit caused by the stroke has resolved, or, if it is a severe stroke, approximately two weeks after the onset of the stroke. Indirect anticoagulants and aspirin are rarely used together. Of course, selection of cardiac therapy itself is also necessary.

For arterio-arterial embolisms and occlusive pathology of the main arteries of the head, taking aspirin, ticlopidine, and dipyridamole is effective. The most optimal is individual testing of the patient’s blood reaction to a particular prescribed drug. This method has been successfully used in our clinic for several years. Treatment and prevention of recurrent cerebral hemorrhages are based primarily on carefully selected antihypertensive therapy, and the prevention of recurrent ischemic strokes is based on ECG and blood pressure monitoring.

In conclusion, it should be emphasized once again that for strokes there is not and cannot be a single universal remedy or treatment method that radically changes the course of the disease. The prognosis for life and recovery is determined by a combination of timely and comprehensive general and specific measures in the first days of the disease, including, among others, constant correction of homeostasis - a determining factor, without normalization of which all subsequent treatment becomes ineffective, as well as active neurosurgical manipulations along with early physical and psychological rehabilitation . First of all, this applies to strokes of moderate and severe severity. A clear understanding of the pathogenetic mechanisms underlying strokes is precisely the key with which it is possible to select reasonable and effective treatment within the first hours of the onset of development of vascular brain damage and ensure a favorable prognosis.

Surgery

Surgical methods occupy a certain place in the prevention of ischemic strokes, especially in cases of severe stenosis or occlusion of the carotid and vertebral arteries, embologenic, heterogeneous atherosclerotic plaques (endarteriectomy, revascularization - see “Medical Newspaper” No. 21 of 03/19/99).

Surgical methods of treatment for cerebellar infarctions against the background of acute obstructive hydrocephalus, as well as drainage of the cerebral ventricles, are currently used with high efficiency. The feasibility of other surgical interventions in the acute period of ischemic stroke requires additional evidence.

Acute cerebrovascular accident (ACVA) of ischemic type in the middle cerebral artery basin (I65) is a sharply occurring focal neurological and/or cerebral symptomatology caused by focal ischemic disorders in the brain, lasting longer than 24 hours.

Prevalence of strokes: 1-4 cases per 1000 people per year. Ischemic stroke accounts for 70-85% of cases.

Risk factors: hypertension, lipid metabolism disorders, smoking, increased body weight, diabetes mellitus, alcohol abuse, sedentary lifestyle.

Acute cerebrovascular accident occurs as a result of atherosclerotic damage to the vessels of the head, cardiogenic embolism in heart disease, increased blood clotting, etc.

Symptoms of acute cerebrovascular accident

Before the onset of stroke, precursors may appear in the form of short-term neurological disorders. In 75% of cases, an ischemic episode occurs during sleep. Symptoms appear over several minutes or hours and may gradually increase. An increase in blood pressure is typical on the first day of the disease. Patients are concerned about the following complaints: headache (90%), weakness (75%) and/or numbness (70%) in one half of the body/limbs, decreased vision (30%), speech impairment (45%). 15% of patients may deny the presence of weakness/numbness in the limbs.

A neurological examination reveals a general cerebral syndrome, contralateral hemiplegia, hemianesthesia, homonymous hemianopsia, adversion of the head and concomitant deviation of the eyes, central paralysis of the face, tongue on the contralateral half of the lesion, motor-sensory aphasia, alexia, acalculia. Anosognosia, a disorder of the body diagram, is determined by damage to the non-dominant hemisphere.

Diagnosis of acute cerebrovascular accident

To identify the etiology of stroke of ischemic type, the following diagnostic methods are necessary:

• Blood tests (electrolytes, hemostasis indicators, glucose, lipid spectrum, antiphospholipid antibodies).
• Electrocardiography, blood pressure measurement.
• Auscultation of vessels on the extremities, duplex scanning, transcranial Dopplerography of precerebral arteries.

• Computed tomography (CT) of the brain shows a hypodense zone 12-24 hours after the development of an ischemic stroke. SPECT (in earlier stages of cerebral ischemia).

• Cerebral angiography (stenosis, occlusion, ulceration, aneurysm).

Differential diagnosis:

• Acute hypertensive encephalopathy.
• Dysmetabolic or toxic encephalopathy.
• Migraine stroke.
• Traumatic brain injury.
• The debut of multiple sclerosis.

Treatment of acute cerebrovascular accident

• Maintaining vital functions of the body, antihypertensive drugs (at blood pressure 200/120 mm Hg), anticoagulants (the appropriateness of prescription is determined by the duration of the disease and concomitant pathology), antiplatelet agents, vasoactive drugs (Cavinton, Actovegin, Cinnarizine) , "Instenon"), neuroprotectors ("Cerebrolysin", "Ceraxon", "Piracetam", "Gliatilin", "Semax"), "Reopoliglyukin", "Trental", decongestants ("Lasix", "Mannitol").
• Passive exercise therapy, breathing exercises, speech therapy classes.
• Consider thrombolysis upon admission within 3-6 hours of illness.
• Rehabilitation activities.
• Secondary prevention.

Treatment is prescribed only after confirmation of the diagnosis by a medical specialist.

Essential drugs

There are contraindications. Specialist consultation is required.

• (anticoagulant). Dosage regimen: IV or SC in the initial dose - IV (injection) 5000 IU, maintenance: continuous IV infusion - 1000-2000 IU/h (20000-40000 IU/day), pre-diluted in 1000 ml of isotonic NaCl solution; regular IV injections - 5000-10000 IU every 4-6 hours; s/c (deep) - 15,000-20,000 IU every 12 hours or 8,000-10,000 IU every 8 hours.
• (diuretic). Dosage regimen: intramuscularly or intravenously (slow stream) 20-60 mg 1-2 times a day, if necessary, the dose can be increased to 120 mg. The drug is administered for 7-10 days or more, and then the drug is taken orally.
• (nootropic drug). Dosage regimen: administered intramuscularly or intravenously, starting from 2.0-4.0 g/day, quickly increasing the dose to 4-6 g/day. After the condition improves, the dose is reduced and switched to oral administration - 1.2-1.6 g / day. (0.4 g 3-4 times a day).
• (a drug that improves cerebral circulation). Dosage regimen: intravenously 20-25 mg in 500 ml infusion solution. Within 2-3 days, the dose can be increased to no more than 1 mg/kg/day. The average course duration is 10-14 days. After completing the course of intravenous therapy, it is recommended to continue treatment with Cavinton tablets, 2 tablets 3 times a day.
• (vasodilator, improves microcirculation). Dosage regimen: two intravenous infusions per day (morning and afternoon), at a dose of 200 mg (2 amps of 5 ml) or 300 mg (3 amps of 5 ml) in 250 ml or 500 ml of 0.9% solution sodium chloride or Ringer's solution.

Content

Cerebral infarction or ischemic stroke is a dangerous disease with a very high mortality rate. It is very important to find the right approach to its treatment, because this is the only way to save the patient’s life. It is worth talking in more detail about the features of the treatment of this pathology.

Acute ischemic cerebrovascular accident

During a stroke, neurons in a specific area of ​​the brain are damaged and die. An ischemic stroke causes neurological disorders that do not disappear after a day. A person can paralyze one half of the body, and speech is severely impaired. He may partially or completely lose his vision. This happens if the arteries supplying blood to the brain stop functioning due to a blood clot or ruptured blood vessel. Without receiving it, the organ tissues begin to die.

When a person develops an ischemic stroke, their life changes dramatically. He becomes less active and acts lost. Possible facial distortion. If you ask the patient to smile, then instead of a proper smile there will be only a specific twisted grimace. Motor functions are impaired, and it is difficult for the patient to navigate in space. It is difficult for a person to answer the most ordinary questions. His limbs stop obeying him.

Acute stroke can occur for many reasons, but all of them in one way or another lead to the development of heart and vascular diseases. Stroke symptoms appear periodically throughout the day. This often happens at night. Stroke is one of the main reasons that young able-bodied people become disabled. The degree to which a person can get rid of the neurological disorders described above depends on how quickly the disease is identified and the correct treatment tactics are chosen.

Basic therapy for stroke

It got its name because it applies to all types of acute cerebrovascular accidents. Basic treatment is aimed at maintaining the patient's life chances until the type of stroke is determined, and begins immediately after the patient enters the hospital. After this, when the nature of the disease is established, differentiated therapy is carried out. Basic treatment is a set of specialized measures, the main goals of which are the following:

• normalize respiratory function;
• stabilize the functioning of the heart and blood vessels (it is very important to reduce blood pressure with sodium solution and other drugs);
• maintain water balance;
• protect brain cells from damage;
• prevent or eliminate swelling of brain tissue;
• prevent pneumonia;
• apply symptomatic treatment.

Thrombolytic therapy for stroke

Its second name is thrombolysis. Currently, this is the only truly effective method of bringing a person back to life after a stroke. Thrombolytic treatment is aimed at restoring blood flow in a vessel that has been damaged due to a blood clot or atherosclerotic plaque in the acute period. This allows you to protect brain tissue from destruction and increase the chances of a favorable outcome. With thrombolysis, neurological pathologies disappear quickly and almost completely.

Thrombolytic treatment of ischemic stroke in the acute period involves the administration of drugs that dissolve blood clots, thereby restoring blood flow. Therapy is suitable only for this type of acute cerebrovascular accident. The procedure is effective only when 6 hours have not passed since the formation of the blood clot. There are two types of thrombolysis:

1. Standard. An outdated system in which the patient was simply given an intravenous drip with pharmacological drugs. It was carried out only after a long, detailed examination and had many contraindications and consequences.
2. Selective. The drug for dissolving the blood clot is injected specifically into the canal of the damaged artery, and not just into the vein, due to which it works faster and more accurately.

Thrombolytic treatment of ischemic stroke in the acute period is strictly prohibited when:

• bleeding of any origin;
• aortic dissection;
• arterial hypertension;
• liver diseases;
• recent surgery;
• acute renal failure;
• pregnancy.

Thrombolytic treatment of stroke is carried out with the following drugs:

• Streptokinase, Urokinase (1st generation);
• Alteplase, Prourokinase (2nd generation);
• Tenecteplase, Reteplase (3rd generation).

Medicines to improve brain circulation

Ischemic stroke of the brain is treated with the following medications:

1. Piracetam. Prescribed under almost any conditions, it increases cerebral blood flow.
2. Aminalon. A medicine for normalizing blood microcirculation in the brain and inhibiting neurological pathologies. It will help you get out of the acute period faster.
3. Phenotropil. Increases blood flow, helps improve memory and concentration.
4. Vinpocetine. Vasoactive drug to improve blood circulation.
5. Phenibut. A drug to stimulate brain activity.
6. Glycine. It not only improves blood circulation in the brain, but also helps to quickly end the acute period and helps fight depression.
7. Vaso collected. Effectively improves blood circulation.
8. Cerebrolysin. A very good drug for extensive stroke, which is administered intravenously.
9. Cortexin. Helps in the treatment of ischemic stroke in the acute period, as well as at the stage of early stabilization, when therapeutic massage is prescribed.
10. Pentoxifylline.
11. Instenon. Improves cerebral circulation.
12. Gliatilin. Stroke medication is prescribed in the acute period. If the patient is in a coma in the intensive care unit, then the drug must be prescribed.
13. Calcium blockers.

Antiplatelet drugs for stroke

These drugs trigger the blood clotting process. The most famous among them, used in the treatment of ischemic stroke in the acute period, are Aspirin, Dipyridamole, Sulfinpyrazone, Ticlopidine. All of these medications are recommended for the prevention of recurrent acute cerebrovascular accident. It is worth noting that the advisability of using antiplatelet agents for stroke is still questionable in medicine. The drugs are used according to the following principles:

1. Aspirin. Depending on the situation, 30 to 325 mg per day is prescribed.
2. Dipyridamole. 0.5 g three times a day.
3. Sulfinpyrazone.
4. Ticlopidine. 2.5 g three times a day.

Antiplatelet drugs have side effects, so before treating a stroke, you need to consult a doctor, weigh all the risks and act only under the supervision of specialists. Among the undesirable actions are the following:

1. Aspirin causes gastrointestinal problems.
2. Taking dipyridamole can cause headache, nausea, weakness, and rash, but side effects are very rare.
3. Sulfinpyrazone leads to various complications. As a result of taking it, gastritis and kidney stones may appear. Rash and anemia are common.
4. Ticlopidine may cause bowel problems.

Blood clotting drugs

The second name is anticoagulants. As a rule, stroke in the acute period is treated with Nadroparin, Heparin, Enoxaparin, Dalteparin, Fraxiparin. The action of the drugs is aimed at preventing the growth of blood clots and preventing neurological pathologies from progressing. Anti-clotting drugs are also prescribed to prevent recurrent strokes. They have a number of contraindications, so they are always prescribed with caution. It is important to understand that these medications do not help reduce blood clots, but simply prevent them from growing.

Heparin is a direct-acting blood clotting blocker that is prescribed first. It is injected into a vein several times a day. Injections under the skin or into the muscle are also acceptable, but they are not nearly as effective. Along with it, and also at the rehabilitation stage, it is necessary to take indirect anticoagulants: Dicumarin, Pelentan, Sinkumar, Phenilin. All of them are available in tablets. The dosage is calculated separately for each patient. The period of admission can be up to several years.

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