What does onmk mean in honey language. Consequences of onmc by ischemic type. Necessary restorative actions during onmc

Definition of the concept

Vascular diseases of the brain are attracting the attention of scientists all over 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, the ONMK classification has been adopted, according to which the following are distinguished:

1) transient disorders of cerebral circulation (PNMC), transient ischemic attack (TIA);

2) meningeal hemorrhage;

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

4) acute hypertensive encephalopathy (OGE).

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

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

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

Stroke the same is called an acute violation of cerebral circulation, 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 ONMK, the leading role belongs to GB, symptomatic arterial hypertension, atherosclerosis, or their combination. Less commonly, cerebral vasculitis is a cause of cerebral vasculitis as a manifestation of collagenosis (rheumatism, periarteritis nodosa, systemic lupus erythematosus), specific arteritis, blood diseases, MI, congenital heart defects, mitral valve prolapse, etc.

The etiology of ischemic stroke is atherosclerosis, its combination with GB, GB, cerebral vasculitis with collagenoses, blood diseases (leukemia, erythremia), MI, congenital heart defects, etc.

Mechanisms of the onset and development of the disease (Pathogenesis)

In hypertensive cerebral crises, apparently, the leading role is played by the disruption of autoregulation of cerebral vessels with symptoms of excessive brain hyperemia, vasodilation, slowing blood flow, increased permeability of the vascular wall with the development of perivasal edema, and in severe cases, microhemorrhage. The mechanism of angiospasm is also not excluded. In TIA, one of the important mechanisms is transient ischemia in the area of ​​an atherosclerotic vessel that occurs during atherosclerotic occlusion or congenital anomalies, as well as in the presence of extracerebral factors (decreased systemic blood pressure, decreased heart rate, 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 the computed tomography method into the diagnosis of PNMC, it was found that in a number of cases the development of PNMC is associated with microhemorrhages and microinfarctions.

The clinical picture of the disease (symptoms and syndromes)

HA-type PNMK develops against the background of high blood pressure, significantly exceeding its usual level in the patient, most often in the daytime and against the background of stressful situations. It is characterized by growing cerebral symptoms: headache, which at first may be local in nature (more often in the occiput), and then becomes diffuse, bursting, pulsating, accompanied by nausea, vomiting, non-systemic dizziness, noise and ringing in the ears, and occasionally impaired consciousness (it short-term loss, stunning). With a severe course of PNMK due to the development of cerebral edema, more prolonged switching off of consciousness is possible, up to the development of stupor and superficial coma, convulsive syndrome (usually generalized seizures), meningeal symptoms. This condition is regarded as OGE. Consequently, HA-type PNMK is mainly characterized by general cerebral symptoms, and in addition to vegetative and disorders - hyperemia of the skin of the face, neck, upper chest, hyperhidrosis, tachycardia, etc. A transient neurological deficit is possible: nystagmus, revitalization and asymmetry of tendon reflexes, inconsistent pathological signs. If PNMK is accompanied by more persistent neurological symptoms, - transient dysfunctions of the cranial nerves (oculomotor, facial, hypoglossal, etc.), short-term speech impairments, paresis, sensory disorders, this is evidence in favor of PNMK of the HA type with focal manifestations.

With TIA in the clinic of the disease, focal symptoms of lesions of the nervous system usually prevail, which are very diverse and depend on the vascular basin. With TIA in the carotid artery basin, paresthesia is most often in half of the tongue, in the area of ​​the lips, face, arms, less often legs, mono- or hemiparesis, speech impairment in case of damage to the left carotid artery in right-handers. Less commonly, seizures such as Jacksonian epilepsy of motor or sensory type are observed, sometimes - oculo-pyramidal syndrome (decreased vision on the side of pathology with contralateral hemiparesis and hemihypesthesia). With TIA in the vertebrobasilar basin, systemic dizziness, nystagmus, loss of visual field, diplopia, photopsia and darkening in the eyes, ataxia, dysarthria, weakness in the limbs. TIA in the vertebrobasilar basin is observed 2 times more often than in the carotid one. In cases where neurological symptoms in 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, secondary hemorrhage into ischemic tissue. As a consequence of these processes, an increase in intracranial pressure develops with dislocation of the brain and compression of vital formations of the trunk or compression ischemia of the cerebral cortex, a sharp decrease in the level of wakefulness and a deepening of neurological deficit with sometimes prognostically unfavorable outcome, including the development of a persistent vegetative state and brain death.

Cerebral edema is defined as an excessive accumulation of fluid in the brain tissue, which leads to an increase in the volume of the latter. The more pronounced the cerebral edema, the more severe the course of 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 through 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 an increase in the permeability of the blood-brain barrier, an increase in the entry of protein macromolecules into the intracellular space. This type of edema is characteristic of the subacute (clock) stage of cerebral catastrophe and can be observed both in heart attacks and in cerebral hemorrhages. Interstitial edema is often due to acute obstructive hydrocephalus and is usually seen on CT as a “periventricular light” (see below).

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

Diagnosis of the disease

Stroke diagnosis is methodologically carried out 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 established - 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 specified.

Stage I

The diagnosis of stroke as such rarely causes significant difficulties for doctors. The main role in this 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, the development of persistent neurological deficits in the form of motor, sensory and often speech disorders in persons, as a rule, over 45 years of age against the background of significant emotional, physical stress, immediately after sleeping 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 vessels of the lower extremities, etc.) or risk factors make the initial diagnosis more reliable.

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

II stage

The most difficult and responsible task is an accurate and quick diagnosis of the nature of a stroke, since in the acute period of the disease it is these moments that largely determine the further tactics of treatment, including surgical, 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, every 4-5th patient has a 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 the data of the clinic, it is highly desirable to carry out a CT scan of the brain as a priority, since the timeliness and effectiveness of the assistance provided largely depend on this. In general, computed tomography of the brain is the international standard for the diagnosis of stroke.

The accuracy of diagnosing hemorrhages with CT reaches almost 100%. In the absence of indications of hemorrhage on CT and the presence of appropriate clinical and anamnestic data indicating 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 matter on tomograms, which is often observed in the first hours after the development of a stroke. In about 80% of cases, CT of the brain detects a zone of reduced density, clinically corresponding to a cerebral infarction, within the first days after the onset of the disease.

Magnetic resonance imaging is more sensitive than CT in the first hours of a cerebral infarction and almost always detects changes in brain matter that are invisible with conventional CT, as well as changes in the brain stem. However, MRI is less informative for cerebral hemorrhages. Therefore, the CT method is still widely used even in the best 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 urgent medical and surgical procedures, and is also important for predicting the further course of the disease. The role of CT is also difficult to overestimate here. As for the mechanisms of the development of acute disorders of cerebral circulation, they, of course, are of great importance for the correct choice of treatment tactics for the patient from the very first days of stroke, but in about 40% of cases it is not possible to accurately establish the pathogenesis of stroke, despite a carefully worked out anamnesis, clinical picture development of the disease and all the 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.) is necessary already in the acute period, since the choice of therapy depends on this (thrombolysis, regulation of general hemodynamics, treatment of atrial fibrillation, etc.). etc.). It is also important to prevent early recurrent episodes of heart attacks.

Treatment of the disease

Approach to patients with acute stroke. Organizational matters

Patients with acute stroke should be admitted to the hospital 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 justified treatment is effective in a later period. The optimal is hospitalization of patients in a multidisciplinary hospital with modern diagnostic equipment, including computer or MRI scanners and angiography, where there is also an angioneurological department with an intensive care unit and an intensive care unit with a specially allocated unit (beds) and trained personnel for managing these patients. An indispensable condition is the presence of a neurosurgical department or a team of neurosurgeons in the hospital, since about a third of patients need consultation or 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 stunning to coma), increasing symptoms, indicating signs of brain stem involvement, as well as severe violations of vital functions require hospitalization of the patient in the intensive care unit (ICU). It is advisable to stay in the same departments and stroke patients with severe disorders of homeostasis, decompensated cardiopulmonary, renal and endocrine pathology.

Urgent measures upon admission

Examination of the patient upon admission to the emergency room should begin with an assessment of the adequacy of oxygenation, the level of blood pressure, the presence or absence of seizures. Providing oxygenation, if necessary, is carried out by setting the air duct and cleansing the airways, and, if indicated, by transferring the patient to mechanical ventilation. The indications for starting mechanical ventilation are: RaO2 - 55 mm Hg. and below, VC is less than 12 ml / kg of body weight, as well as clinical criteria - tachypnea 35-40 per minute, increasing cyanosis, arterial dystonia. It is not customary to lower blood pressure if it does not exceed 180-190 mm Hg. for systolic and 100-110 mm Hg. for diastolic pressure, since autoregulation of cerebral blood flow is impaired in stroke, and cerebral perfusion pressure often directly depends on the level of systemic arterial pressure. Antihypertensive therapy is carried out with caution with small doses of beta-blockers (obzidan, atenolol, etc.) or angiotensin-converting enzyme blockers (renitek, etc.), which do not cause significant changes in the autoregulation of cerebral blood flow. In this case, blood pressure is reduced by about 15-20% of the initial values.

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

The neurological examination of the patient upon admission should be brief and include an assessment of the level of wakefulness (Glasgow coma scale), the state of the pupils and oculomotor nerves, motor, and, if possible, the sensitive sphere, 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, it is recommended that patients with stroke be hospitalized in clinics that have the necessary diagnostic equipment.

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

When CT detects signs of cerebral hemorrhage and evaluates its volume and localization, together with neurosurgeons, the question of the expediency of surgical intervention is discussed. In ischemic strokes, panarteriography of the main arteries of the head or arteriography on the side of the brain lesion is recommended (if a vessel is suspected of having a blockage). Revealing the occlusion of the arteries supplying the brain requires a solution to 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, size of the aneurysm and to decide on the operation. In doubtful cases, a lumbar puncture can be performed. It is optimal to carry out all these measures immediately in the emergency room and in the 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 therapy and prevention of various kinds of somatic complications, usually developing against the background of acute cerebrovascular accidents (ACVI), as well as specific methods of treating the stroke itself, depending on its nature ...

General measures: maintaining the optimal level of oxygenation, blood pressure, monitoring and correcting 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), control over the state of the bladder, intestines, skin care. From the very first hours, it is necessary to conduct passive gymnastics and massage of hands and feet as an indispensable and most effective condition for the prevention of one of the main causes of mortality in stroke - pulmonary embolism (PE), as well as pressure sores and early post-stroke contractures.

Daily care of critically ill patients should include: every 2 hours, turning from side to side; every 8 hours wiping the patient's body with camphor alcohol; enemas (at least every other day); administration of fluid to the patient at the rate of 30-35 ml per kg of body weight per day; every 4-6 hours a toilet of the oral and nasopharynx with the help of suction followed by washing with warm infusion of 5% chamomile solution or its substitutes. Antibiotic therapy, if necessary, with the obligatory intake of adequate doses of antifungal drugs. When signs of disseminated intravascular coagulation (DIC) appear - the introduction of low molecular weight heparin in doses of 7500 IU 2-3 times a day subcutaneously. When transferring a patient to mechanical ventilation - carrying out in full the measures detailed in the manuals for resuscitation and neuroresuscitation.

Currently, hyperventilation and osmotic diuretics are most widely used to treat cerebral edema. Hyperventilation (lowering 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. Mannitol is the most commonly used osmotic diuretic. The drug is recommended to be administered intravenously at an initial dose of 0.5-1.5 g / kg of body weight for 20 minutes, and then at a dose equal to half of the initial dose, 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 borne in mind that exceeding the osmolarity level above 320 mosm / l, as well as prolonged use of mannitol, is dangerous, since electrolyte changes, renal pathology and other disorders occur, which are prognostically extremely unfavorable for the patient. The introduction 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, as well as barbiturates, have not been shown to be effective in treating cerebral edema in stroke, although their cytoprotective effects are debated.

Acute obstructive hydrocephalus (OBH) is based on pronounced extraventricular compression of the cerebrospinal fluid pathways or their clogging with blood clots (intraventricular occlusion). This condition, which can only be diagnosed by CT data, develops most often in the first two days with subtentorial and almost one third of the supratentorial hemorrhages, as well as with cerebellar infarctions exceeding a third of its hemisphere. In subtentorial lesions, compression of the IV ventricle, a sharp increase in the III and lateral ventricles, in supratentorial lesions, compression of the III and the homolateral lateral ventricle or their filling with blood clots with a significant increase in the contralateral lateral ventricle are revealed by tomography. The increase in EHC leads to an increase in the volume of the brain, an increase in intracranial pressure and a deepening of the dislocation of brain structures, including its trunk. This, in turn, causes a sharp violation of the CSF flow and an increase in the difference in pressure between the supra- and subtentorial spaces, which further enhances the displacement and deformation of the trunk. There is a saturation of the brain substance with cerebrospinal fluid from the dilated ventricles. At the same time, a CT scan reveals the already mentioned X-ray phenomenon - "periventricular fluorescence" - a zone of low density in the white matter of the brain around the expanded part of the ventricular system.

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

Breakthrough of blood into the ventricular system and subarachnoid space has previously always been considered a prognostically poor, 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 for one or another of its localization. The closer to the midline of the hemispheres is the hemorrhage, 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 the subarachnoid space is observed very often in patients with hemorrhagic stroke. This is usually noted with hematoma volumes over 30-40 cm3. There are no reliably proven effective treatments for this complication yet.

Secondary hemorrhage into necrotic tissue, as a rule, is observed on the 1-10th day with extensive, large and medium-sized cerebral infarctions. Like the previous two complications, it is reliably established on the basis of CT data. Revealing 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 the contraindications to it.

Specific treatments for stroke

Hemorrhagic stroke

In every second case, the cause of intracerebral nontraumatic hemorrhage is arterial hypertension, about 10-12% is due to cerebral amyloid angiopathy, approximately 10% is due to the intake of anticoagulants, 8% is due to tumors, all other causes account for about 20%. Pathogenetically, intracerebral hemorrhages can develop either due to rupture of a vessel, or by diapedesis, usually against the background of previous arterial hypertension.

Currently, there are no specific medical methods for treating hemorrhagic stroke; antihypoxants and antioxidants are used. The treatment is based on general measures to maintain homeostasis and correct the main complications (see above). Epsilon-aminocaproic acid is not indicated, as its hemostatic effect does not reach the target, while the danger of PE increases. An important and often decisive method of treating hemorrhagic stroke is surgical intervention - removal of a hematoma by an open or stereotaxic method, taking into account its volume, localization 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. According to 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 of their causing, clinical picture of development, prognosis and, of course, treatment.

At the heart of cerebral infarctions is developing ischemia associated with complex cascades of interaction of blood components, endothelium, neurons, glia and extracellular spaces of the brain. The depth of such interactions generates varying degrees of traumatization of 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 opportunities." From this it follows that drugs that are different in 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 are two strategic directions: reperfusion and neuronal protection, aimed at protecting poorly functioning or almost non-functioning, but still viable neurons located around the heart attack (zone of "ischemic penumbra").

Reperfusion is possible by thrombolysis, vasodilation, increased perfusion pressure and improved rheological properties of blood.

Thrombolytic therapy

The main cerebral thrombolytics are urokinase, streptokinase and their derivatives, as well as tissue plasminogen activator (TAP). All of them act directly or indirectly as plasminogen activators. Currently, the effectiveness of the use of thrombolytics, in particular TAP, 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 development at a dose of 0.9 mg / kg body weight intravenously, with small foci on CT and blood pressure not higher than 190/100 mm Hg, no history of strokes, peptic ulcer disease, etc. Thrombolytic therapy, as a rule, does not eliminate the initial causes that caused the blockage of blood vessels, since residual athero stenosis persists, but restores blood flow. Hemorrhagic complications with the use of various thrombolytics, according to various sources, range from 0.7 to 56% (!), Which depends on the time of administration and the properties of the drug, the size of the heart attack, compliance with the entire complex of contraindications to this type of drug therapy.

Vasodilators

Clinical use of vasodilators usually does not give positive results, possibly due to the fact that these drugs increase intracranial pressure, lower 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).

Increased cerebral perfusion pressure and improved blood rheology

One of the most well-known methods used for this purpose is hemodilution. It is based on two principles of influence on 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 (rheopolyglucin, rheomacrodex, etc.), only if the patient's hematocrit level exceeds 40 IU, in volumes ensuring its reduction to 33-35 IU. At the same time, 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 introduction of rheopolyglucin for the purpose of correcting the hematocrit for more than 7-8 days starting from the moment of the development of a stroke, except in special cases, is not justified. If the effectiveness of the hemodilution method has been proven in about half of the international multicenter controlled trials, 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 in the acute phase of cerebral infarction. It can be used in two modes - 150-300 mg each or in small doses of 1 mg / kg body weight daily. There is practically 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 a different action in the acute period, including ticlopidine and dipyridamole (curantil), 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 is not directly associated with a decrease in mortality and disability in patients. At the same time, there is strong evidence that heparin (low molecular weight heparin) actually prevents deep venous thrombosis and therefore the risk of PE (see above).

Neuroprotection

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

Currently, a whole spectrum of drugs with neuroprotective properties is distinguished: postsynaptic glutamate antagonists; presynaptic glutamate inhibitors (lubeluzole); calcium channel blockers, antioxidants (emoxipin, 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 the effectiveness of the vast majority of neuroprotective drugs. In cases where some authors still manage to obtain positive results in the course of research, they are almost always questioned by other specialists conducting their clinical trials according to approximately the same standards. In this regard, the validity of their use in patients is not entirely clear. On the whole, there is no doubt that neuroprotection is highly promising as a method of treatment. Its widespread introduction is undoubtedly a matter for the near future.

Prevention of repeated disorders of cerebral circulation

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

Indirect anticoagulants are recommended for cardioembolic strokes due to atrial fibrillation. If there are contraindications to their use, it is recommended to use aspirin. The optimal timing for initiating anticoagulant therapy after an acute episode has not yet been determined. To reduce the risk of cerebral hemorrhage, it is believed that initial treatment should begin with aspirin and continue until the underlying deficiency caused by the stroke has resolved, or, if it is a severe stroke, about two weeks after its onset. Indirect anticoagulants and aspirin are rarely used together. Of course, the selection of cardiac therapy itself is also necessary.

With arterio-arterial embolism, occlusive pathology of the main arteries of the head, aspirin, ticlopidine, dipyridamole are effective. The most optimal is individual testing of the patient's blood reaction to one or another 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 prevention of recurrent ischemic strokes is based on ECG and blood pressure monitoring.

In conclusion, it should be emphasized once again that with strokes there is not and cannot be a single universal remedy or method of treatment that radically changes the course of the disease. The prognosis for life and recovery is determined by a combination of timely and full-fledged general and specific measures in the first days of the disease, including, among others, constant correction of homeostasis - a determining factor, without which normalization 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 high severity. A clear understanding of the pathogenetic mechanisms underlying strokes is precisely the key with which it is possible to choose a reasonable and effective treatment already in the first hours after the onset of the development of vascular brain damage, to ensure a favorable prognosis.

Surgery

A certain place in the prevention of ischemic strokes is occupied by surgical methods, especially with gross stenosis or occlusion of the carotid and vertebral arteries, embologic, heterogeneous atherosclerotic plaques (endarteriectomy, revascularization - see "Medical Newspaper" No. 21 dated 19.03.99).

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

Many people ask the question of what ONMK is and what the consequences are after it. This article will analyze the main reasons for the manifestation of CVA and the consequences.

ONMK - what is it

Many people who have nothing to do with medicine probably do not know what ACVA is. So, an acute circulatory disorder in the brain is a stroke that causes damage and death of brain cells. The cause of this disease is the formation of a blood clot in the blood vessels of the brain or the rupture of some blood vessels, which causes the death of a huge number of nerve cells and blood cells. According to statistics, it is ONMK that is in first place among diseases that cause human death. Every year all over the world, as indicated by the federal registry of patients with stroke, 14 percent of people die from this disease, as well as 16 from other types of diseases of the circulatory system.

Reasons why ACVE may appear

In order to prevent the appearance of this disease, it is necessary to pay attention to your lifestyle from an early age. For example, constant sports activities can significantly reduce the possibility of CVA manifestations. What it is, you already know, some of the causes of this ailment will be considered further.

As a rule, this disease does not come suddenly, very often the diagnosis of "stroke" can be established as a consequence of certain diseases. Often the cause of this condition can be:

• hypertension;
• obesity is the most common cause indicated by the federal registry of a patient with stroke;
• diabetes;
• high cholesterol;
• heart disease;
• alcohol and smoking;
• various kinds of medicines;
• high hemoglobin levels;
• according to the federal register ONMK, another reason is age;
• traumatic brain injury;
• genetic predisposition and so on.

Now it is clear what ONMK is. These are the consequences of a wrong lifestyle. Therefore, it is very important to monitor your health and physical condition.

Ischemic stroke

Ischemic stroke is a stroke caused by damage to brain tissue and impaired blood flow to one or another of its parts.

In the majority of ischemic stroke patients, general diseases of the cardiovascular system are found. Such diseases also include arteriosclerosis, heart disease (arrhythmia, rheumatic defect), diabetes mellitus.

ACVA of this type is characterized by sharp and frequent manifestations of pain, the consequence of which is a deterioration in blood circulation in the cerebral cortex. As a rule, such attacks can make themselves felt several times per hour and last for 24 hours.

CVA is included in the international classification of diseases 10 revision

ONMK codes (ICD 10):

1. I63.0. Human cerebral infarction as a consequence of thrombosis of the precerebial blood arteries.
2. I63.1. Human brain infarction after embolism of the precerebral blood arteries.
3. I63.2. Cerebral infarction as a consequence of stenosis of the precerebral blood arteries or non-thinning blockage of the cerebral arteries.
4. I63.3. ACVA as a consequence of thrombosis of the blood arteries of the brain.
5. I63.4. Stroke due to embolism of cerebral blood vessels.
6. I63.5. ACVA as a consequence of stenosis of blood arteries or their non-thinning blockage.
7. I63.6. Non-pyogenic cerebral infarction as a consequence of cerebral blood vein thrombosis.
8. I63.8. Brain infarction for other reasons.
9. I63.9. Unrefined ONMK.
10. I64.0. Unsophisticated stroke, which manifests itself as a hemorrhage or heart attack.

CVA codes (ICD 10) allow doctors to quickly establish the classification of the disease, the true cause of its appearance and determine the necessary treatment. Therefore, this classification is the main tool in the hands of a doctor, which allows you to save the life of a person.

Causes of ischemic stroke ACVA

The main reason for the manifestation of ischemic stroke is a decrease in blood flow to the brain. Very often, this is why an ischemic stroke becomes the cause of death of a person.

So, we found out the features of ischemic stroke, what it is and what are its symptoms.

This, as a rule, is the result of damage to the vessels of the neck and some arteries of the brain in the form of occlusive lesions and stenosis.

Let's find out the main reasons for its occurrence. The main factors that can affect the decrease in blood flow include the following:

1. Occlusions and stenoses of the main arteries of the brain and vessels of the neck.

2. Thrombotic layers on the surface of an atherosclerotic plaque.

3. Cardiogenic embolism, which occurs when there are artificial valves in the human heart.

4. Stratification of the great arteries of the cervical spine.

5. Hyalinosis of small arteries, as a result of which microangiopathy develops, which leads to the formation of lacunar infarction of the human brain.

6. Hemorheological changes in blood composition, which occurs with vasculitis, as well as coagulopathies.

Very rarely, the cause of the manifestation of this disease can be external trauma of the carotid arteries and various inflammatory processes, which can significantly impair the permeability of blood through the vessels.

Also, very often, the main cause of cerebral stroke can be osteochondrosis of the cervical spine, during which the blood vessels are significantly pinched, which can lead to a decrease in blood flow. Patients with osteochondrosis are constantly advised to massage the cervical spine and smear it with various warming drugs that can significantly expand blood vessels and improve blood circulation.

ACMC symptoms

Signs of this disease can very often appear sharply or increase gradually. As a rule, the main symptoms of this disease include speech and visual impairment in a patient, impaired reflexes, movement coordination, headaches, disorientation, sleep disturbance, noise in the head, memory impairment, paralysis of the face, tongue, lack of sensation of some limbs, and so on. Further.

In acute disorders of cerebral circulation, the following consequences are characteristic - a cerebral stroke, impaired blood circulation in the cerebral cortex during the formation of blood clots in the vessels and main blood arteries of the head, etc.

With symptoms of acute cerebrovascular accident, which last more than a day, a stroke is diagnosed. At the first stage of this disease, severe headache, dizziness, nausea, gag reflexes, and so on may also appear. If you do not immediately pay attention to these manifestations, this can lead to the death of a person.

According to the registry of patients with stroke, according to statistics, the main cause of these manifestations can be high blood pressure, which can be observed during intense physical exertion. A sharp increase in blood pressure can cause rupture of blood vessels in the brain, followed by hemorrhage and internal cerebral hematoma.

In most cases, the above symptoms are observed before ischemia. As a rule, they can last several hours or several minutes. As a rule, with the manifestation of stroke ischemic type, the symptoms constantly become more active. According to experts, with the manifestation of these symptoms, most people experience disorientation, as a result of which a person loses vigilance, coordination of movements worsens, so many patients simply fall asleep. According to statistics, 75 percent of ischemic-type infarction attacks occur during sleep.

Diagnosis of acute cerebrovascular accident by ischemic type

To identify the problem, it is necessary to carry out diagnostics and various studies on the ICD system. ACMC doctors will be able to diagnose after the following procedures:

• glucose, hemostasis, antiphospholipid antibodies.
• Electrocardiography of changes in blood pressure.
• the cerebral cortex, as a result of which it will be possible to detect the affected parts of the brain and the resulting hematomas without any problems.
• Cerebral angiography and so on.

Treatment of acute cerebrovascular accident in ischemic type

The most common cause of death is ONMK. Treatment should therefore be supervised by experienced doctors. With this disease, the following therapy is carried out:

1. Maintenance of vital functions of the human body. The patient should use antihypertensive drugs when the blood pressure in the body is 200 to 120 mm. rt. Art. The use of anticoagulants is also prescribed (they are used for concomitant pathologies and are used for a long time after the normalization of the condition), vasoactive drugs, antiplatelet agents, decongestants, neuroprotectors, and so on.
2. Various sets of exercises are performed - speech therapy classes and breathing exercises.
3. The issue of thrombolysis upon admission of a patient to a medical facility within 3-6 hours from the moment of manifestation of the disease is considered.
4. Secondary prevention of the disease.
5. Various rehabilitation measures are being carried out, and so on.

As a rule, the main points of treatment will be prescribed only by a doctor, who will familiarize himself in more detail with the victim's illnesses.

In the event that there are suspicions of an acute violation of cerebral circulation, it is necessary to contact highly qualified specialists in this field of activity. As a rule, first of all, it will be necessary to undergo magnetic resonance imaging, which can accurately determine all pathologies of the cerebral cortex. Thus, it will be possible to prevent the possibility of complications of the disease and begin treatment even before it fully manifests itself. A specialized department of ONMK, as a rule, should have special equipment that will significantly improve treatment.

Disease statistics among population groups

This disease very often worries not only elderly people, but also young people. This disease today attracts the attention of tens of thousands of scientists from all over the world, as it very often worries people of different age groups. A lot of cases were recorded when ACVA began to progress already in young people, and even in infants. Scientists cite statistics according to which it turned out the following number of diseases per 100,000 population at different ages.

The number of stroke patients at different ages is shown in the table.

Female persons

Male persons

Quantity affected

Federal register of a patient with stroke

The federal register keeps records of the number of patients with a particular disease. He studies the progression of certain diseases and the reasons for their development. CVA is a disease that is also accounted for. This register contains all information about patients and their history.

The Federal Register states that mortality due to diseases of the vascular system of the body is in the first place today. As a rule, 50 percent of deaths are associated precisely with acute circulatory disorders of the brain (ACVA), that is, the main cause of death is precisely a stroke. Every year in the Russian Federation, an average of 400-450 thousand cases of stroke are recorded, that is, every one and a half minutes a person develops this disease. Of the total number of patients, approximately 40 percent die.

Every year the number of patients with acute cerebrovascular accident is growing significantly. Thus, according to the federal register of the ONMK department, in 1996 in the Moscow region 16 thousand victims were registered, and in 2003 this figure increased to 22 thousand patients. From this it can be concluded that acute cerebrovascular accident is one of the most progressive diseases today.

According to the federal register of ONMK, about a million people live in our country who have already survived this disease, while it is worth noting that a third of the victims are people of working age. After illness among people of this age, only 25 percent of the victims were able to return to work. Based on these data, it can be determined that stroke is one of the most progressive and dangerous diseases.

The federal register of patients with acute cerebrovascular accidents every day is replenished with a huge number of patients, but the number of cases remains unchanged. This is justified by the fact that the life expectancy after the disease is significantly reduced. Therefore, it is worth constantly monitoring your health in order to prevent the manifestations of this disease.

Consequences of acute cerebrovascular accident

The consequences of stroke can be very different - from mild to severe. Very often, after an acute violation of cerebral circulation, people receive the following consequences:

• Loss of sensitivity in a specific area of ​​the body. Very often, the sensitivity of the hands, feet, fingers, the right or left side of the body, the muscles of the face, the tongue, and so on is lost.
• Weakness or complete paralysis of the arm or arms, leg or legs, an individual part of the body, or the right or left side of the body.
• Very often victims lose hearing, vision, taste, sensitivity of certain nerve endings of the limbs of the body.
• Often after stroke, patients feel dizziness, double vision, noise in the head, and so on.
• Confused speech.
• Difficulty in pronunciation and word selection when speaking.
• Lack of ability to recognize specific parts of the body.
• Involuntary urination.
• Lack of ability to move.
• Lack of orientation in space and loss of balance.
• Unexpected fainting spells and so on.

Departments of ONMK conduct constant rehabilitation sessions for patients. As a rule, under the supervision of experienced doctors, it is possible to eliminate these consequences and completely restore the sensitivity of the body. After a certain period of time after the manifestation of ischemic attacks or stroke, a person will be able to fully return to a normal lifestyle. It is worth considering that the so-called can last for a long period of time. If they are observed throughout the day, this will lead in most cases to a full stroke. They can also occur over a period of time. Thus, some people experience these symptoms several times a year. And after each such manifestation, a certain period of rehabilitation is required.

The consequences of stroke can be very different, since the area of ​​brain damage can be different.

First aid for stroke

The very first thing to do when symptoms of this disease are detected is to call an ambulance. In no case should the patient be disturbed without reason during the manifestation of the symptoms of this disease, therefore, immediately after the first signs, it is necessary to isolate him.

At the next stage, all patients with stroke should lie in such a way that the upper body and head are raised, and it is also necessary to rub the collar zone of the body in order to facilitate breathing for the patient. It is also necessary to provide fresh air to the room where the patient is located (open the window, doors, and so on).

In the event that the patient has vomiting spasms, it is necessary to turn his head to the left side and clean the oral cavity with gauze or just a clean napkin. This is done to prevent vomit from entering the lungs when breathing, which can lead to additional problems.

One of the most common symptoms of stroke is an epileptic seizure - a person completely loses consciousness, after a few seconds a wave of seizures sweeps through the body, which can last for several minutes. It is also worth noting that such attacks can be repeated several times.

Everyone can ask a question about what needs to be done in this case. The patient should be turned on his side, put a pillow under his head. Holding your head, it is necessary to constantly wipe the secretions from the mouth so that they do not enter the respiratory organs. To prevent the patient from biting his tongue, it is necessary to insert a comb or a stick into his mouth. It is worth noting that under no circumstances should you press the patient's arms and legs or lean on him with the whole body. Such actions can significantly increase seizures or cause various kinds of injury - dislocations, fractures. It is only necessary to slightly hold the patient's legs so that he cannot injure himself or others. Do not use ammonia, as it can cause respiratory arrest in the patient.

If, after an attack, the victim's heart stops beating or breathing stops completely, it is necessary to urgently do direct heart massage and mouth-to-mouth breathing or mouth-to-nose breathing.

Now you know the basic exercises and ACVA standards that can save a person's life during seizures.

How to prevent the occurrence of stroke diseases

Based on the above statistics, it can be seen that this disease manifests itself even in children. It is easy to guess that every year there are more and more people who suffer from this disease. All this is associated with unhealthy diet, inactive lifestyle and high mental stress.

If a person does not lead an active lifestyle and constantly spends time at the computer, he has a good chance of contracting this disease. Obesity, as it was said, is the main cause of this disease, which is why the issue of maintaining physical fitness is very relevant today for the younger generation.

Heavy loads are also very often a source of problems, since with an increase in blood pressure there is a risk of rupture of blood arteries and veins, which will also lead to stroke. Therefore, it is necessary to constantly go in for sports, lead an active lifestyle, eat right - and the risk of stroke will significantly decrease.

The most deadly and terrible disease in our time is precisely ONMK. You already know what it is and why this disease occurs, so you must adhere to the above recommendations in order to prevent the disease in the future.

CRITERIA FOR DIAGNOSTICS OF SEPARATE FORMS OF ONMK

Stroke includes acute disorders of cerebral circulation, characterized by a sudden (within minutes, less often - hours) appearance of focal neurological symptoms (motor, speech, sensory, coordination, visual and other disorders) and / or cerebral disorders (changes in consciousness, headache, vomiting, etc.), which persist for more than 24 hours or lead to the death of the patient in a shorter period of time due to a cause of cerebrovascular origin.

Stroke is divided into hemorrhagic and ischemic (cerebral infarction). A minor stroke is distinguished, in which the impaired functions are fully restored during the first 3 weeks of the disease. However, such relatively mild cases are observed in only 10-15% of stroke patients.

Transient cerebrovascular accidents (PNMC) are characterized by the sudden onset of focal neurological symptoms that develop in a patient with vascular disease (arterial hypertension, coronary artery disease, rheumatism, etc.) and last for several minutes, less often hours, but no more than a day and end with a complete recovery of the disturbed functions. Transient neurological disorders with focal symptoms that develop as a result of short-term local cerebral ischemia are also referred to as transient ischemic attacks (TIA). A special form of PNMC is acute hypertensive encephalopathy. More often, acute hypertensive encephalopathy develops in patients with malignant arterial hypertension and is clinically manifested by a sharp headache, nausea, vomiting, impaired consciousness, convulsive syndrome, in some cases accompanied by focal neurological symptoms.

The appearance of TIA or minor stroke indicates a high risk of repeated and, as a rule, more severe stroke (since the pathogenetic mechanisms of these conditions are largely similar) and requires prophylaxis of repeated stroke.

II. STEP-BY-STEP MANAGEMENT OF PATIENTS WITH ACCI

Basic principles of the organization of medical care in stroke.

I. Diagnosis of stroke at the prehospital stage.

II. The earliest possible hospitalization of all patients with stroke.

III. Diagnostics of the nature of a stroke.

IV. Clarification of the pathogenetic subtype of ACVA.

V. Choice of optimal treatment tactics.

Vi. Rehabilitation and measures for the secondary prevention of stroke.

III. PRE-HOSPITAL ACTIVITIES

Main goals:

1. Diagnosis of stroke.

2. Carrying out a complex of urgent medical measures.

3. Implementation of emergency hospitalization of the patient.

Assistance is provided by linear or specialized neurological ambulance teams.

1. ACVA is diagnosed with the sudden appearance of focal and / or cerebral neurological symptoms in a patient with a general vascular disease and in the absence of other causes (trauma, infection, etc.)

2. Urgent therapeutic measures are determined by the need to ensure adequate ventilation and oxygenation, maintain the stability of systemic hemodynamics, and relieve convulsive syndrome.

Assessment: the number and rhythm of respiratory movements, the state of the visible mucous membranes and nail beds, participation in the act of breathing of the auxiliary muscles, swelling of the cervical veins.

Measures: if necessary - cleansing the upper respiratory tract, setting the air duct, and if indicated (tachypnea 35-40 per minute, increasing cyanosis, arterial dystonia) - transferring the patient to artificial lung ventilation (ALV). Hand-held breathing apparatus (ADR-2, Ambu type), apparatus with an automatic drive are used.

2.2. Maintaining an optimal level of systemic blood pressure.

You should refrain from urgent parenteral administration of antihypertensive drugs if systolic blood pressure does not exceed 200 mm Hg, diastolic blood pressure does not exceed 120 mm Hg, and the calculated mean blood pressure does not exceed 130 mm Hg. (mean blood pressure = (systolic blood pressure - diastolic blood pressure): 3 + diastolic blood pressure). Reducing blood pressure should not be more than 15-20% of the initial values. It is preferable to use drugs that do not affect the autoregulation of cerebral vessels - alpha - beta - blockers, beta - blockers, angiotensin converting enzyme (ACE) inhibitors.

In case of arterial hypotension, it is recommended to use drugs that have a vasopressor effect (alpha - adrenomimetics), drugs that improve myocardial contractility (cardiac glycosides), volume substitutes (dextrans, plasma, saline solutions).

2.3. Relief of convulsive syndrome (anticonvulsants - tranquilizers, antipsychotics; if necessary - muscle relaxants, inhalation anesthesia).

3. Stroke is a medical emergency, therefore all patients with stroke should be hospitalized.

The time of hospitalization should be minimal from the onset of the development of focal neurological symptoms, preferably within the first 3 hours from the onset of the disease.

A contraindication for hospitalization of a patient with stroke is only an agonal state.

IV. HOSPITAL ACTIVITIES

IV.1. Organizational activities

Hospitalization of patients with stroke is carried out in a multidisciplinary hospital that has the necessary X-ray and radiological (including computed tomography (CT), magnetic resonance imaging (MRI), angiography) and ultrasound equipment, as well as:

a) a department for patients with cerebrovascular accidents with an intensive care unit;

b) a neuroresuscitation department or an intensive care unit with specially allocated beds and trained personnel for the management of patients with stroke;

c) department of neurosurgery.

Patients who have:

Altered level of wakefulness (from mild stupor to coma);

Breathing and swallowing disorders;

Severe disorders of homeostasis;

Decompensation of cardiac, renal, hepatic, endocrine and other functions against the background of stroke.

Patients with stroke, who do not require urgent resuscitation and neurosurgical care, are hospitalized in the department for patients with cerebrovascular accidents. At the same time, patients are admitted to the intensive care unit:

With unstable (progressive) neurological symptoms ("developmental stroke");

With severe neurological deficits, requiring intensive individual care;

With additional somatic disorders.

IV.2. Diagnostic measures

IV.2.1. STEP OF HOSPITAL DIAGNOSTICS

The goal is to confirm the diagnosis of stroke and determine its nature (ischemic, hemorrhagic).

Requirements:

1. A neurologist, resuscitator, therapist and neurosurgeon provide assistance to patients with stroke.

2. Patients with stroke should have the right of priority instrumental and laboratory examination so that the diagnostic process is as complete and fast as possible (within an hour from the moment of hospitalization).

3. For patients with TIA, diagnostic examinations are also carried out in a hospital and to the same extent as for patients with stroke.

All patients with a presumptive diagnosis of stroke are shown computed tomography (CT) of the head, which in most cases makes it possible to distinguish hemorrhagic stroke from ischemic stroke and to exclude other diseases (tumors, inflammatory diseases, CNS injuries). Magnetic resonance imaging (MRI) of the head is a more sensitive method for diagnosing cerebral infarction at an early stage. However, it is inferior to CT in detecting acute hemorrhages, and therefore is less suitable for emergency diagnosis.

In the case when CT or MRI is not available, echoencephaloscopy (M-ECHO) is mandatory, in the absence of contraindications - lumbar puncture and CSF examination.

Lumbar puncture is contraindicated for inflammatory changes in the lumbar region and for suspected intracranial volumetric process (danger of dislocation disorders).

BASIC DIAGNOSTIC MEASURES FOR PATIENTS WITH ACI

(regardless of the nature of the stroke)

1. Clinical blood test with counting the number of platelets, hematocrit.

2. Blood group, Rh factor.

3. Blood test for HIV.

4. Blood test for HBs antigen.

5. Wasserman reaction.

6. Biochemical blood test: sugar, urea, creatinine, bilirubin, ACT, ALT, cholesterol, triglycerides, high and low density lipoproteins.

7. Electrolytes (potassium, sodium), plasma osmolality.

8. Blood gas composition, acid base balance.

9. Screening - study of the hemostasis system: fibrinogen, fibrinolytic activity (lysis of euglobulins), thrombin time, activated partial thrombin time (APTT), prothrombin test with the calculation of the international normalized ratio (MHO), blood coagulation time, bleeding time, D - dimer, platelet aggregation (adrenaline-, ADP-, collagen - induced), blood viscosity.

10. Clinical urine analysis.

12. X-ray of the chest organs.

13. X-ray of the skull.

14. Consultation of a therapist.

15. Consultation with an ophthalmologist.

Additional diagnostic measures (according to indications)

1. Glycemic profile.

2. Glucosuric profile.

3. Consultation of an endocrinologist.

4. EEG (in the presence of convulsive syndrome).

5. Study of markers of intravascular activation of the hemostasis system: fragments of prothrombin I + II, thrombin-antithrombin complex (TAT) and protein C system, fibrin-peptide A, soluble fibrin-monomer complexes, D-dimer, plasmin-antiplasmin complex (PAP).

6. Assessment of intravascular platelet aggregation: platelet factor 4, thromboxane B2, beta - thrombomodulin.

Result: verification of the diagnosis of stroke and the nature of the stroke (ischemic, hemorrhagic).

IV.2.2. THE STAGE OF "DEEP" HOSPITAL DIAGNOSTICS is a direct continuation of the previous stage.

PURPOSE: to clarify the pathogenetic subtype of stroke:

A. Ischemic stroke:

Atherothrombotic (includes stroke due to arterio-arterial embolism);

Cardioembolic;

Hemodynamic;

Lacunar;

Stroke of the type of hemorheological microocclusion.

B. Hemorrhagic stroke:

Non-traumatic subarachnoid hemorrhage (hypertensive, ruptured aneurysm);

Parenchymal hemorrhage;

Cerebellar hemorrhage;

Subarachnoid - parenchymal;

Ventricular hemorrhage;

Parnchymal - ventricular.

A. ISCHEMIC STROKE.

Mandatory examinations (carried out within an hour from the moment of hospitalization):

1. Ultrasound examination of extra- and intracranial vessels, including duplex scanning.

2. Emergency cerebral angiography - performed only in cases when it is necessary to make a decision on drug thrombolysis.

3. Echocardiography.

Additional studies (carried out during the first 1 - 3 days):

1. Planned cerebral angiography:

It is carried out to clarify the cause of ischemic stroke,

The scope of the study includes angiography of the branches of the aortic arch, the main arteries of the head, and intracranial vessels.

2. Holter ECG monitoring.

3. Daily monitoring of blood pressure.

Special studies are carried out if there are indications during the acute period of the disease, their types and volume are determined by a council with the participation of relevant specialists - a hematologist, a cardiologist - a rheumatologist, etc.

Result: clarification of the leading mechanism for the development of stroke and the pathogenetic subtype of ischemic stroke, the choice of patient management tactics, including the decision on the need for surgical correction.

B. HEMORRHAGIC STROKE.

Purpose: to clarify the pathogenetic basis of hemorrhage (hypertensive, due to rupture of an aneurysm or arterio-venous malformation)

Diagnostic measures:

1. Cerebral angiography:

1.1 Indications:

Subarachnoid hemorrhage;

Atypical localization of intracerebral hematoma (according to CT, MRI);

Ventricular hemorrhage.

1.2 Scope of the study: bilateral carotid and vertebral angography.

2. Transcranial Doppler sonography - to identify and assess the severity of cerebral vasospasm, its dynamics during treatment.

An emergency consultation with a neurosurgeon is indicated:

1. Hemorrhagic stroke:

a) supra- and subtentorial hematoma;

b) subarachnoid hemorrhage.

2. Cerebellar infarction.

3. The presence of acute obstructive hydrocephalus.

Routine consultation with a neurosurgeon and / or vascular surgeon is indicated for ischemic stroke, PNMK in the presence of hemodynamically significant stenosis, occlusion of the main arteries of the head, tortuosity of the neck arteries, stenosis / occlusion of the cerebral arteries.

Indications for surgical treatment of patients with stroke.

A. Hemorrhagic stroke.

1. Intracerebral hemispheric hemorrhages with a volume of more than 40 ml (according to CT of the head).

2. Hemorrhage in the cerebellum.

3. Obstructive hydrocephalus.

B. Aneurysms, arterio-venous malformations, arterio-sinus fistulas, accompanied by various forms of intracranial hemorrhage and / or cerebral ischemia.

B. Ischemic stroke.

1. Cerebellar infarction with severe secondary stem syndrome, brainstem deformity (according to CT / MRI of the head), obstructive hydrocephalus.

IV.3. Management of patients with various forms of stroke (see Appendix III)

General principles of treatment of patients with stroke include basic therapy (regardless of the nature of stroke) and differentiated therapy, taking into account the nature and pathogenetic subtype of stroke.

IV.3.1. Basic therapy measures for stroke

1. Measures aimed at normalizing the function of external respiration and oxygenation (sanitation of the airways, installation of an air duct, tracheal intubation, if necessary - carrying out mechanical ventilation).

2. Regulation of the function of the cardiovascular system:

a) maintaining blood pressure by 10% higher than the numbers to which the patient is adapted (when carrying out antihypertensive therapy, beta-blockers, ACE inhibitors, calcium channel blockers are preferable, with arterial hypotension - drugs that have a vasopressor effect (dopamine, alpha-adrenomimetics) and volume replacement therapy (dextrans, one-group fresh frozen plasma);

b) antiarrhythmic therapy for cardiac arrhythmias;

c) with ischemic heart disease (postinfarction cardiosclerosis, angina pectoris) - antianginal drugs (nitrates);

d) drugs that improve the pumping function of the myocardium - cardiac glycosides, antioxidants, optimizers of tissue energy metabolism.

3. Control and regulation of homeostasis, including biochemical constants (sugar, urea, creatinine, etc.), water-salt and acid-base balance.

4. Neuroprotection - a complex of universal methods of protecting the brain from structural damage - begins at the prehospital stage (it may have some peculiarities in different subtypes of stroke).

5. Measures aimed at reducing cerebral edema (have features depending on the nature of the stroke).

6. Measures for the prevention and treatment of somatic complications: pneumonia, pressure ulcers, uroinfection, disseminated intravascular coagulation, phlebothrombosis and pulmonary embolism, contractures, etc.

7. Symptomatic therapy, including anticonvulsant, psychotropic (with psychomotor agitation), muscle relaxants, analgesics, etc.

IV.3.2. General principles of pathogenetic treatment for ischemic stroke

The current strategy for the treatment of patients with ischemic strokes is based on early diagnosis of the pathogenetic subtype of stroke.

The basic principles of pathogenetic treatment of ischemic stroke include:

1) restoration of blood flow in the ischemic zone (recirculation, reperfusion).

2) maintaining the metabolism of brain tissue and protecting it from structural damage (neuroprotection).

Basic recirculation methods

1. Restoration and maintenance of systemic hemodynamics.

2. Drug thrombolysis (recombinant tissue plasminogen activator, alteplase, urokinase).

3. Hemangiocorrection - normalization of the rheological properties of blood and the functionality of the vascular wall:

a) antiplatelet agents, anticoagulants, vasoactive agents, angioprotectors;

b) extracorporeal methods (hemosorption, ultrahemofiltration, laser blood irradiation);

c) gravitational methods (cyt-, plasmapheresis).

4. Surgical methods of recirculation: the imposition of extra-intracranial microanastomosis, thrombectomy, reconstructive operations on the arteries.

Basic methods of neuroprotection

1. Restoration and maintenance of homeostasis.

2. Drug protection of the brain.

3. Non-drug methods: hyperbaric oxygenation, cerebral hypothermia.

Decongestant therapy for ischemic stroke

1. Osmotic diuretics (controlled by plasma osmolality).

2. Hyperventilation.

3. An additional anti-edema effect is exerted by the use of neuroprotective agents and the maintenance of homeostasis.

4. With the development of occlusive hydrocephalus in cerebellar infarction - according to indications, surgical treatment is performed (decompression of the posterior cranial fossa, ventricular drainage).

IV.3.2.1. Peculiarities of treatment of various pathogenetic subtypes of ischemic stroke

When a stroke is verified due to obstruction of the adducting artery (atherothrombotic, including due to arterio-arterial embolism, cardioembolic infarction) upon admission of the patient in the first 3-6 hours from the onset of the disease and no changes in CT examination of the head (hemorrhagic changes, mass effect) , with a stable blood pressure not higher than 185/100 mm Hg. it is possible to carry out drug thrombolysis: recombinant tissue plasminogen activator (rt-PA) at a dose of 0.9-1.1 mg / kg of the patient's weight, 10% of the drug is administered intravenously by bolus (when the intra-arterial catheter is standing - intravenously), the rest of the dose - intravenous drip for 60 minutes). However, the need for a highly specialized preliminary examination of a potential recipient, including CT of the head, angiography, a significant risk of hemorrhagic complications of thrombolytic therapy, currently does not allow recommending this method of treatment for widespread use and forces it to be limited to specialized angioneurological centers.

1. CARDIOEMBOLIC STROKE:

a) anticoagulants - direct action in the acute period with the subsequent transition to long-term maintenance therapy with indirect anticoagulants;

b) antiplatelet agents;

c) neuroprotective agents;

d) vasoactive drugs;

e) adequate treatment of cardiac pathology (antiarrhythmic drugs, antianginal drugs, cardiac glycosides, etc.).

2. ATHEROTHROMBOTIC STROKE:

a) antiplatelet agents (platelet, erythrocyte);

b) with a progressive course of the disease (increasing thrombosis), direct anticoagulants are shown with a transition to indirect ones;

c) hemodilution (low molecular weight dextrans, one-group fresh frozen plasma);

d) angioprotectors;

e) neuroprotectors.

3. HEMODYNAMIC STROKE:

a) restoration and maintenance of systemic hemodynamics:

Preparations of vasopressor action, as well as - improving the pumping function of the myocardium;

Volume-replacing agents, mainly - biorheological drugs (plasma), low-molecular-weight dextrans;

In case of myocardial ischemia - antianginal drugs (nitrates);

With dysrhythmia - antiarrhythmics, with conduction disturbances (bradyarrhythmias) - implantation of a pacemaker (temporary or permanent);

b) antiplatelet agents;

c) vasoactive drugs (taking into account the state of systemic hemodynamics, blood pressure, cardiac output, the presence of dysrhythmias);

d) neuroprotective agents.

4. LACUNAR STROKE:

a) basis - optimization of blood pressure (ACE inhibitors, angiotensin II receptor antagonists, beta-blockers, calcium channel blockers);

b) antiplatelet agents (platelet, erythrocyte);

c) vasoactive agents;

d) antioxidants.

5. STROKE BY HEMORHEOLOGICAL MICROOCCLUSION TYPE:

a) hemangiocorrectors of various groups (antiplatelet agents, angioprotectors, vasoactive drugs, low molecular weight dextrans);

b) in case of insufficient efficiency, the development of DIC-syndrome - the use of direct anticoagulants, and then - and indirect action;

c) vasoactive drugs;

d) antioxidants.

6. ACUTE HYPERTONIC ENCEPHALOPATHY:

a) a gradual decrease in blood pressure by 10-15% of the initial level (preferably the use of easily dosed ACE inhibitors, alpha - beta - blockers, beta - blockers, the use of vasodilating drugs is contraindicated);

b) dehydrating therapy (saluretics, osmotic diuretics);

c) hyperventilation;

d) neuroprotective agents;

e) angioprotectors;

f) hemangiocorrectors (mainly biorheological drugs - plasma, low molecular weight dextrans);

g) symptomatic treatment (anticonvulsant, antiemetic drugs, analgesics, etc.).

IV.3.3. General principles of treatment of hemorrhagic stroke

The basics of basic therapy for hemorrhagic stroke have some peculiarities.

1. Regulation of the function of the cardiovascular system:

a) in hypertensive hemorrhages, the optimization of blood pressure has a pathogenetic significance;

b) in some cases, patients need long-term controlled arterial hypotension. The means of choice for this method of treatment is sodium nitroprusside, which is administered through an infusomat with continuous monitoring of blood pressure.

2. Activities aimed at reducing cerebral edema:

a) the use of membrane stabilizers (dexazone, 4-8 mg IM 4 times a day);

b) hyperventilation;

c) the use of neuroprotective agents;

d) restoration and maintenance of homeostasis;

e) surgical methods - hematoma removal, ventricular drainage, decompression.

3. Neuroprotection (see. Ischemic stroke).

4. Measures for the prevention and treatment of somatic complications: DIC - syndrome, phlebothrombosis and pulmonary embolism (use of hemangiocorrectors - antiplatelet agents, anticoagulants, low molecular weight dextrans). The decision on their appointment should be made by a council with the participation of a therapist - hematologist.

Pathogenetic treatment of hemorrhagic stroke (conservative)

1. Application of means of angioprotective action, which help to strengthen the vascular wall.

2. In case of subarachnoid hemorrhage and intracerebral hematomas with a breakthrough of blood into the cerebrospinal fluid system - prevention of vascular spasm (vasoselective calcium channel blockers - nimodipine up to 25 mg / day IV drip or 0.3-0.6 every 4 hours inside; vasoactive drugs).

3. To improve microcirculation and prevent secondary ischemic lesions of the brain tissue, low molecular weight dextrans, antiplatelet agents are used under conditions of continuous monitoring of blood pressure, parameters of the hemostasis system.

V. Rehabilitation of patients with stroke

V.1. The main tasks of rehabilitation.

1. Restoration (improvement) of impaired functions.

2. Mental and social readaptation.

3. Prevention of post-stroke complications (spasticity, contractures, etc.).

V.2. Indications and contraindications for rehabilitation.

All patients with stroke are in need of rehabilitation measures.

Contraindications to active rehabilitation are:

1.severe somatic pathology in the stage of decompensation;

2. mental disorders.

V.3. Basic principles of rehabilitation.

The main principles of rehabilitation are: early onset, duration and consistency, stages, complexity, active participation of the patient.

The duration of rehabilitation is determined by the terms of restoration of impaired functions: the maximum improvement in motor functions is noted in the first 6 months, everyday skills and working capacity - within 1 year, speech functions - within 2-3 years from the moment of CVA development.

V.4. Organization of staged care for patients with stroke.

1. Angioneurological department of a multidisciplinary hospital.

2. Department of early rehabilitation of a general hospital:

Patients are transferred, as a rule, 1 month after the onset of a stroke,

A full course of rehabilitation treatment is carried out,

The duration of the course is 1 month.

3. Further treatment is determined by the severity of the neurological defect:

A) in the presence of motor, speech and other disorders, the patient is sent to a rehabilitation center or a rehabilitation sanatorium;

B) in the absence of pronounced neurological disorders, the patient is sent to a local sanatorium of a neurological or cardiovascular profile;

B) Patients with severe residual neurological disorders or those who have contraindications for active rehabilitation are discharged home or transferred to a specialized nursing hospital.

4. Patients with moderate severity of residual neurological disorders continue rehabilitation on an outpatient basis (rehabilitation departments or polyclinic offices).

5. Repeated courses of inpatient rehabilitation are indicated with continued restoration of impaired functions and the prospect of restoration of working capacity.

Vi. Prevention of repeated stroke

The risk of developing a stroke in reversible forms of cerebrovascular pathology (TIA, minor stroke) is high and amounts to at least 5% per year. Prevention of repeated stroke should be carried out taking into account the pathogenetic mechanisms of their development.

If the cause of TIA or minor stroke was cardiogenic embolism, in addition to correction (medication, surgical) of cardiac pathology, the administration of indirect anticoagulants or antiplatelet agents is indicated. In case of detection of a small deep (lacunar) infarction, pathogenetically associated with hypertension, the main direction of preventing recurrent ACVA becomes an adequate antihypertensive therapy.

It is more difficult to prevent stroke in patients with atherosclerotic changes in the carotid arteries (atherothrombotic, hemodynamic stroke, as well as due to arterio-arterial embolism). The significance of the pathology of the carotid artery for a particular patient is determined by the individual characteristics of the structure of the vascular system of the brain, the severity and prevalence of its lesion, as well as the structure of atherosclerotic plaques.

Currently, in patients with TIA and minor stroke with pathology of the carotid arteries, two directions of stroke prevention are generally recognized:

1.the use of antiplatelet agents;

2. carrying out an angiosurgical operation: elimination of stenosis of the carotid artery, if there are contraindications to it, cranio-cerebral bypass grafting can be performed.

Prescribing antiplatelet agents to patients who have had a TIA or minor stroke reduces their risk of recurrent stroke by 20-25%. In the case of significant stenosis of the carotid artery (more than 70% of the vessel lumen) on the side of the affected cerebral hemisphere, carotid endarterectomy as a means of preventing recurrent stroke is significantly more effective than the use of antiplatelet agents. A prerequisite is the operation in a specialized clinic, in which the level of complications associated with the operation does not exceed 3-5%. In case of stenosis of the carotid artery up to 30%, preference is given to drug prophylaxis. Surgery may become necessary if a complicated medium-sized plaque becomes a source of recurrent cerebral embolism.

Prevention of repeated stroke in patients with hemorrhagic stroke is:

1. in patients with arterial hypertension - in carrying out adequate antihypertensive therapy;

2. in patients with hemorrhage due to rupture of an arterial aneurysm or arterio-venous malformation - in carrying out an angiosurgical operation.

The abbreviated classic name of the pathology in acute cerebrovascular accident looks like "ischemic stroke." If hemorrhage is confirmed, then - for hemorrhagic.

In ICD-10, ONMK codes may differ, depending on the type of violations:

• G45 - the established designation of transient cerebral attacks;
• I63 - recommended for statistical registration of cerebral infarction;
• I64 is a variant used for unidentified differences between cerebral infarction and hemorrhage, used when a patient is admitted in an extremely serious condition, unsuccessful treatment and imminent death.

In terms of frequency, ischemic strokes exceed hemorrhagic strokes by 4 times, and are more associated with general human diseases. The problem of prevention and treatment is considered in programs at the state level, because 1/3 of patients who have had the disease die in the first month and 60% remain persistent disabled people who require social assistance.

Why is there a lack of blood supply to the brain?

Acute cerebral circulation disorder of the ischemic type is more often a secondary pathology, arises against the background of existing diseases:

• arterial hypertension;
• widespread atherosclerotic vascular lesions (up to 55% of cases develop due to pronounced atherosclerotic changes or thromboembolism from plaques located in the aortic arch, brachiocephalic trunk or intracranial arteries);
• transferred myocardial infarction;
• endocarditis;
• heart rhythm disturbances;
• changes in the valvular apparatus of the heart;
• vasculitis and angiopathy;
• vascular aneurysms and developmental anomalies;
• blood diseases;
• diabetes mellitus.

Up to 90% of patients have changes in the heart and the great arteries of the neck. The combination of these reasons dramatically increases the risk of ischemia.

Possible compression of the vertebral artery by the processes of the vertebrae

Transient attacks are often caused by:

• spasm of the arterial brainstem or short-term compression of the carotid, vertebral arteries;
• embolization of small branches.

The following risk factors can provoke the disease:

• elderly and senile age;
• excess weight;
• the effect of nicotine on blood vessels (smoking);
• experienced stress.

The basis of the influencing factors is the narrowing of the lumen of the vessels through which blood flows to the brain cells. However, the consequences of such a malnutrition can be different in terms of:

A combination of factors determines the form of the disease and clinical symptoms.

Pathogenesis of various forms of acute cerebral ischemia

Transient ischemic attack was previously called transient cerebrovascular accident. It is allocated in a separate form, since it is characterized by reversible disorders, the heart attack focus does not have time to form. Usually, the diagnosis is made retrospectively (after the disappearance of the main symptoms), after a day. Prior to this, the patient is treated like a stroke.

The main role in the development of hypertensive cerebral crises belongs to an increased level of venous and intracranial pressure with damage to the walls of blood vessels, release of fluid and protein into the intercellular space.

Edema of brain tissue in this case is called vasogenic.

The feeding artery is necessarily involved in the development of ischemic stroke. Cessation of blood flow leads to oxygen deficiency in the focus formed in accordance with the boundaries of the basin of the affected vessel.

Local ischemia causes necrosis of an area of ​​brain tissue.

Depending on the pathogenesis of ischemic changes, there are types of ischemic strokes:

• atherothrombotic - develops when the integrity of the atherosclerotic plaque is violated, which causes complete overlap of the internal or external feeding arteries of the brain or their sharp narrowing;
• cardioembolic - the source of thrombosis is pathological growths on the endocardium or heart valves, thrombus fragments, they are delivered to the brain with general blood flow (especially with an open foramen ovale) after attacks of atrial fibrillation, tachyarrhythmias, atrial fibrillation in patients in the postinfarction period;
• lacunar - more often occurs when small intracerebral vessels are damaged in arterial hypertension, diabetes mellitus, differs in the small size of the focus (up to 15 mm) and relatively small neurological disorders;
• hemodynamic - cerebral ischemia with a general decrease in the blood circulation rate and a drop in pressure against the background of chronic heart disease, cardiogenic shock.

With hemodynamic disturbances, blood flow in the vessels of the brain may decrease to a critical level and below

It is worth explaining the variant of the development of strokes of unknown etiology. This happens more often if there are two or more reasons. For example, in a patient with carotid stenosis and atrial fibrillation after an acute heart attack. It should be borne in mind that elderly patients already have stenosis of the carotid arteries on the side of the alleged disorder, caused by atherosclerosis, in the amount of up to half of the vessel lumen.

Stages of cerebral infarction

The stages of pathological changes are conditionally distinguished, they are not necessarily present in every case:

• Stage I - hypoxia (oxygen deficiency) disrupts the process of permeability of the endothelium of small vessels in the focus (capillaries and venules). This leads to the transfer of fluid and protein of the blood plasma into the brain tissue, the development of edema.
• Stage II - at the level of the capillaries, the pressure continues to decrease, which disrupts the functions of the cell membrane, nerve receptors located on it, and electrolyte channels. It is important that all the changes are still reversible.
• Stage III - cell metabolism is disrupted, lactic acid accumulates, a transition to energy synthesis occurs without the participation of oxygen molecules (anaerobic). This type does not allow maintaining the required level of life of cells of neurons and astrocytes. Therefore, they swell and cause structural damage. Clinically expressed in the manifestation of focal neurological signs.

What is the reversibility of pathology?

For timely diagnosis, it is important to establish the period of reversibility of symptoms. Morphologically, this means the preserved functions of neurons. Brain cells are in the phase of functional paralysis (parabiosis), but retain their integrity and usefulness.

The ischemic zone is much larger than the area of ​​necrosis, the neurons in it are still alive

In the irreversible stage, it is possible to identify a zone of necrosis in which the cells are dead and cannot be restored. The ischemic zone is located around it. Treatment is aimed at supporting adequate nutrition of neurons in this area and at least partial restoration of function.

Modern research has shown extensive connections between brain cells. A person does not use all reserves and opportunities in his life. Some cells are able to replace the dead and ensure their functions. This process is slow, so doctors believe that the rehabilitation of a patient after an ischemic stroke should be continued for at least three years.

Signs of perennial circulatory disorders of the brain

In the group of transient disorders of cerebral circulation, clinicians include:

• transient ischemic attacks (TIA);
• hypertensive cerebral crises.

Features of transient attacks:

• in terms of duration, they fit in the period from several minutes to a day;
• every tenth patient after TIA has an ischemic stroke for a month;
• neurological manifestations are not of a gross nature of severe disorders;
• possible mild manifestations of bulbar paralysis (focus in the brain stem) with oculomotor disorders;
• visual impairment in one eye in combination with paresis (loss of sensitivity and weakness) in the limbs of the opposite side (often accompanied by incomplete narrowing of the internal carotid artery).

Features of hypertensive cerebral crises:

• the main manifestations are cerebral symptoms;
• focal signs are rare and poorly expressed.

The patient complains about:

• a sharp headache, often in the back of the head, temples or crown;
• a state of stunnedness, noise in the head, dizziness;
• nausea, vomiting.

• temporary confusion of consciousness;
• excited state;
• sometimes - a short-term attack with loss of consciousness, convulsions.

Signs of a cerebral stroke

Ischemic stroke means the occurrence of irreversible changes in brain cells. In the clinic, neurologists distinguish periods of the disease:

• the most acute - lasts from the onset of manifestations for 2–5 days;
• acute - lasts up to 21 days;
• early recovery - up to six months after the elimination of acute symptoms;
• late recovery - takes from six months to two years;
• consequences and residual effects - over two years.

Some doctors continue to identify minor or focal strokes. They develop suddenly, the symptoms do not differ from cerebral crises, but lasts up to three weeks, then disappears completely. The diagnosis is also retrospective. On examination, no organic abnormalities are found.

Brain ischemia, in addition to general symptoms (headaches, nausea, vomiting, dizziness), manifests itself as local. Their character depends on the artery, which is "turned off" from the blood supply, the state of the collaterals, the dominant hemisphere of the patient's brain.

Consider the zonal signs of blockage of the cerebral and extracranial arteries.

With damage to the internal carotid artery:

• vision is impaired on the side of the blockage of the vessel;
• the sensitivity of the skin on the limbs, the face of the opposite side of the body changes;
• in the same area, muscle paralysis or paresis is observed;
• the disappearance of the speech function is possible;
• inability to be aware of their disease (if the focus is in the parietal and occipital lobes of the cortex);
• loss of orientation in parts of one's own body;
• loss of visual fields.

Narrowing of the vertebral artery at the neck level causes:

• hearing loss;
• nystagmus of the pupils (twitching when deviating to the side);
• double vision.

If the narrowing occurs at the site of the confluence with the basilar artery, then the clinical symptoms are more severe, since the defeat of the cerebellum predominates:

• inability to move;
• disturbed gesticulation;
• chanted speech;
• violation of joint movements of the trunk and limbs.

If there is insufficient blood flow in the basilar artery, manifestations of visual and brainstem disorders (impaired breathing and blood pressure) occur.

With damage to the anterior cerebral artery:

• hemiparesis of the opposite side of the trunk (unilateral loss of sensation and movement), more often in the leg;
• slowness of movements;
• increasing the tone of the flexor muscles;
• loss of speech;
• inability to stand and walk.

Blockage of the middle cerebral artery is characterized by symptoms depending on the defeat of the deep branches (feeding the subcortical nodes) or long (approaching the cerebral cortex)

Violation of patency in the middle cerebral artery:

• with complete blockage of the main trunk, a deep coma occurs;
• lack of sensitivity and movement in half of the body;
• the inability to fix the gaze on the subject;
• loss of visual fields;
• loss of speech;
• inability to distinguish the left side from the right.

Disruption of the patency of the posterior cerebral artery causes:

• blindness in one or both eyes;
• double vision;
• paresis of the gaze;
• seizures;
• large tremor;
• impaired swallowing;
• paralysis on one or both sides;
• violation of breathing and pressure;
• cerebral coma.

When blockage of the optic-geniculate artery appears:

• loss of sensitivity in the opposite side of the body, face;
• severe pain when touching the skin;
• inability to localize the stimulus;
• perverted perception of light, knocking;
• thalamic hand syndrome - the shoulder and forearm are bent, the fingers are extended in the terminal phalanges and bent at the base.

Impaired blood circulation in the zone of the optic tubercle, thalamus is caused by:

• sweeping movements;
• large tremor;
• loss of coordination;
• impaired sensitivity in half of the body;
• sweating;
• early bedsores.

In what cases can ONMK be suspected?

The above clinical forms and manifestations require careful examination, sometimes not of one, but of a group of doctors of different specialties.

Violation of cerebral circulation is very likely if the following changes are found in the patient:

• sudden loss of sensitivity, weakness in the limbs, on the face, especially one-sided;
• acute drop in vision, the onset of blindness (in one eye or both);
• difficulty in pronunciation, understanding of words and phrases, making up sentences;
• dizziness, loss of balance, impaired coordination of movements;
• confusion of consciousness;
• lack of movement in the limbs;
• intense headache.

Additional examination allows you to establish the exact cause of the pathology, the level and localization of the vascular lesion.

Purpose of the diagnosis

Diagnosis is important for the choice of treatment. This requires:

• confirm the diagnosis of stroke and its form;
• to identify structural changes in the brain tissue, the focus area, the affected vessel;
• clearly distinguish between ischemic and hemorrhagic forms of stroke;
• on the basis of pathogenesis, establish the type of ischemia for the initiation of specific therapy in the first 3–6, in order to get into the "therapeutic window";
• to assess the indications and contraindications for drug thrombolysis.

It is practically important to use diagnostic methods on an emergency basis. But not all hospitals have enough medical equipment to operate around the clock. The use of echoencephaloscopy and examination of cerebrospinal fluid give up to 20% of errors and cannot be used to resolve the issue of thrombolysis. The most reliable methods should be used in the diagnosis.

Softening foci on MRI allow differential diagnosis of hemorrhagic and ischemic strokes

Computed tomography and magnetic resonance imaging allows:

• to distinguish a stroke from volumetric processes in the brain (tumors, aneurysms);
• accurately establish the size and localization of the pathological focus;
• determine the degree of edema, violations of the structure of the ventricles of the brain;
• identify extracranial localization of stenosis;
• diagnose vascular diseases that contribute to stenosis (arteritis, aneurysm, dysplasia, venous thrombosis).

Computed tomography is more accessible and has advantages in examining bone structures. And magnetic resonance imaging better diagnoses changes in the parenchyma of brain tissue, the size of the edema.

Echoencephaloscopy can only reveal signs of displacement of the midline structures with a massive tumor or hemorrhage.

Cerebrospinal fluid rarely gives in ischemia a small lymphocytosis with an increase in protein. More often unchanged. If the patient has a hemorrhage, then an admixture of blood may appear. And with meningitis - inflammatory elements.

Vascular ultrasound - Doppler ultrasonography of the neck arteries indicates:

• the development of early atherosclerosis;
• stenosis of extracranial vessels;
• sufficiency of collateral connections;
• the presence and movement of an embolus.

Duplex sonography can determine the condition of the atherosclerotic plaque and arterial walls.

Cerebral angiography is performed if technical capabilities are available for emergency indications. Usually, a more sensitive method is considered in determining aneurysms and foci of subarachnoid hemorrhage. Allows you to clarify the diagnosis of pathology identified on tomography.

Ultrasound of the heart is performed to detect cardioembolic ischemia in heart disease.

Survey algorithm

The examination algorithm for suspected stroke is carried out according to the following plan:

1. examination by a specialist in the first minutes after the patient is admitted to the hospital, examination of the neurological status, clarification of the anamnesis;
2. blood sampling and study of its coagulability, glucose, electrolytes, enzymes for myocardial infarction, hypoxia level;
3. in the absence of the possibility of conducting an MRI and CT scan, make an ultrasound of the brain;
4. lumbar puncture to exclude hemorrhage.

Treatment

The most important in the treatment of cerebral ischemia belongs to the urgency and intensity in the first hours of admission. 6 hours from the onset of clinical manifestations is called the "therapeutic window". This is the time of the most effective application of the thrombolysis technique to dissolve a thrombus in a vessel and restore impaired functions.

Regardless of the type and form of CVA in the hospital, the following are carried out:

• increased oxygenation (filling with oxygen) of the lungs and normalization of respiratory function (if necessary, by transfer and mechanical ventilation);
• correction of impaired blood circulation (heart rate, pressure);
• normalization of the electrolyte composition, acid-base balance;
• reduction of cerebral edema by administering diuretics, magnesia;
• relief of excitement, convulsive seizures with special antipsychotics.

To feed the patient, a semi-liquid table is prescribed, if it is impossible to swallow, parenteral therapy is calculated. The patient is provided with constant care, prevention of bedsores, massage and passive gymnastics.

Rehabilitation starts from the first days

This allows you to get rid of negative consequences in the form of:

• muscle contractures;
• congestive pneumonia;
• DIC syndrome;
• pulmonary embolism;
• lesions of the stomach and intestines.

Thrombolysis is a specific ischemic stroke therapy. The method allows you to preserve the viability of neurons around the zone of necrosis, the return to life of all weakened cells.

The introduction of anticoagulants begins with Heparin derivatives (in the first 3-4 days). Drugs of this group are contraindicated for:

• high blood pressure;
• peptic ulcer;
• diabetic retinopathy;
• bleeding;
• the impossibility of organizing regular monitoring of blood clotting.

After 10 days, they switch to indirect anticoagulants.

Drugs that improve metabolism in neurons include Glycine, Cortexin, Cerebrolysin, Mexidol. Although they do not appear to be effective in the evidence-based medicine base, prescribing results in improvement.

Decompression craniotomy is performed in case of increasing edema in the brain stem

Patients may need symptomatic treatments, depending on the specific manifestations: anticonvulsants, sedatives, pain relievers.

To prevent infection of the kidneys and pneumonia, antibacterial agents are prescribed.

Forecast

Prognosis data are available only for ischemic infarction, other changes are precursors indicating an increased risk of stroke.

The most dangerous indicator of death is atherothrombotic and cardioembolic types of ischemia: during the first month of the disease, from 15 to 25% of patients die. Lacunar stroke ends fatally only for 2% of patients. The most common causes of death:

• in the first 7 days - cerebral edema with compression of the vital centers;
• up to 40% of all deaths occur in the first month;
• after 2 weeks - pulmonary embolism, congestive pneumonia, cardiac pathology.

Patient survival time:

After this period, 16% die per year.

Only 15% of patients return to work

Signs of disability are:

• in a month - up to 70% of patients;
• six months later - 40%;
• by the second year - 30%.

The rate of recovery is most noticeable in the first three months in terms of increased range of motion, while leg functions return faster than arms. Remaining immobility in the hands after a month is an unfavorable sign. Speech recovers years later.

The rehabilitation process is most effective with the patient's volitional efforts, the support of loved ones. Complicating factors are old age, heart disease. Seeing a doctor in the phase of reversible changes will help avoid serious consequences.

My husband was diagnosed with ONMK, stayed in the hospital for a month, then was treated at home for a month. Paresis on the right side, walked on crutches. After 2 months, the paralysis of the left side was treated for 10 days. MRI showed that there was no ACVA at all. Was the course of treatment for STROKE - PARALYCH on the LEFT harm to arms and legs?

Three months after acute cerebrovascular accident, speech disappeared and cannot swallow. We were put back in the hospital. Feed through a tube. What forecast can there be? And are they discharged from the hospital with a probe?

In 2011, she suffered an ischemic stroke on the left side, her functions recovered, but now the left side of her head is numb. In 2014 she did an MRI, blood flow to the brain is 30%, constant headaches, the pressure rises to 140 to 85. The stroke was at a pressure of 128 to 80, working pressure 90 to 60, I'm 65 years old.

Ischemic stroke, its symptoms and treatment

ACVA or acute cerebrovascular accidents is a group of clinical syndromes that result from impaired blood flow to the brain. A thrombus formed in the blood vessels of the brain or damage to them can cause pathology, which leads to the death of a large number of blood and nerve cells. Allocate:

1. ACVA by ischemic type (ischemic stroke).
2. Stroke by hemorrhagic type (hemorrhagic stroke). This diagnosis is made when a cerebral hemorrhage is confirmed.

The above classification is very important for choosing the right treatment method.

A stroke triggered by damage to the brain tissue and critical disturbances in the blood supply to its areas (ischemia) is called ischemic stroke.

The main reason for the manifestation of pathology is a decrease in the amount of blood entering the brain. The following factors and diseases can lead to this:

• Persistent increase in blood pressure.
• Damage to the main arteries of the brain and vessels of the neck in the form of occlusion and stenosis.
• Atherosclerotic changes.
• Inflammation of the connective tissue membrane of the heart.
• Inflammatory processes or injuries of the carotid arteries, which significantly reduce blood flow through the vessels.
• Hemorheological changes in the cellular composition of the blood.
• Cardiogenic embolism.
• Change in heart rate.
• Myocardial infarction.
• Various changes in the heart, as well as in the great arteries of the cervical spine (observed in 91% of patients).
• Diabetes.
• Immunopathological vascular inflammation.
• Pathological violation of the tone of the blood vessels.
• Thrombotic formations on the walls of blood vessels.
• The presence of artificial valves in the heart.
• Smoking.
• Overweight.
• Everyday stress.

At risk are elderly people (however, there are cases of illness in children) and patients suffering from osteochondrosis of the cervical spine, as this leads to significant compression of the blood vessels.

The disease has a wide variety of symptoms. The general symptoms of stroke by ischemic type include sudden headaches, deterioration of speech and vision, impaired reflexes and coordination, nausea, vomiting, dizziness and disorientation of the patient in space, pain in the eyeballs, paralysis of the face and limbs. Psychomotor agitation and short-term loss of consciousness, convulsions are also possible.

There are zonal signs of cerebral artery thrombolization. It is characterized by the following types of violations.

If the internal carotid artery is affected, the patient's vision deteriorates (visual fields are lost), the sensitivity of the skin and speech is impaired, muscle paralysis and loss of orientation in his own body occur.

Disorders of patency in the middle cerebral artery cause disturbances in sensitivity in half of the body, inability to focus on a specific object, loss of visual fields and loss of speech. The patient is unable to distinguish the right side from the left.

If the disorders occur in the posterior cerebral artery, blindness, seizures, complete or partial paralysis, respiratory failure, major tremors and deterioration in swallowing function can occur. In the worst case, a cerebral coma occurs.

With damage to the anterior cerebral artery, there is a one-sided loss of sensitivity, loss of speech. The patient's movements slow down or there is no ability to walk and stand at all.

If the slightest symptoms of pathology are detected, it is necessary to carry out timely treatment of stroke.

The purpose of diagnostics is to determine the required method of treatment. It is very important in the first hour after admission of the patient to be examined by a specialist. Next, the following procedures are carried out:

• Blood sampling to determine blood clotting: viscosity, hematocrit, fibrinogen, electrolytes and antiphospholipid antibodies.
• CT and MRI. This is the most reliable method for detecting acute cerebrovascular accidents. It allows you to correctly determine the type of stroke, exclude tumors and aneurysms, establish the size and localization of the focus, and diagnose vascular diseases.
• Echoencephaloscopy. This technique is not very informative in the first hours of a stroke.
• X-ray examination of the vessels of the brain.
• ECG of changes in blood pressure.
• Ultrasound of the brain. It is used if there is no possibility of computed and magnetic resonance imaging.

The main task is urgent and intensive treatment in the first minutes of the patient's admission, since at this time the thrombolysis technique is effective. This will preserve the vitality of neurons near the zone of necrosis, as well as weakened cells. Further, in the hospital, upon confirmation of ACVE in the patient, treatment is carried out in the following order:

1. 1. A general complex is carried out to maintain the vital functions of the body.
2. 2. If necessary, prescribed antihypertensive drugs, anticoagulants (if the patient has high blood pressure, ulcers, diabetes or bleeding), vasoactive and decongestant drugs, antiplatelet agents and others.
3. 3. To normalize breathing and saturation of the lungs with oxygen, breathing exercises are performed. In extreme cases, artificial lung ventilation is performed.
4. 4. Restore blood circulation.
5. 5. With the help of diuretics, they reduce the swelling of the brain.
6. 6. Prescribe antipsychotic drugs to exclude the possibility of repeated seizures.
7. 7. In case of violation of the swallowing function of the body, the patient is prescribed a semi-liquid diet or parenteral therapy.

Acute ischemic stroke can lead to the following complications:

• paralysis or paresis of one side of the body;
• violations of pain sensitivity of any part of the body;
• loss of taste, hearing, sudden blindness or double vision;
• problems with speech (when talking, it is difficult for the patient to select and pronounce words);
• violations of complex, purposeful movements (apraxia);
• disorders of the swallowing function of the body;
• loss of visual fields;
• spontaneous fainting;
• involuntary urination.

It should be noted that with proper treatment and regular rehabilitation exercises, it is possible to completely eliminate the above complications, as well as to completely restore the patient's body. And after some time, a person can completely return to normal life.

If the slightest suspicion arises, ONMK should immediately call an ambulance. At this time, the patient should not be disturbed for no reason (and it is best to isolate him) and put him in such a position so that the upper body and head are raised. Next, you need to allow the patient to breathe freely. To do this, you need to massage the neck and collar zone and provide fresh air to the room.

If a person has gag reflexes, turn his head to the side and clean the mouth with a tissue or gauze. This will eliminate the risk of vomit entering the respiratory tract.

Quite often, with stroke, an epileptic seizure occurs, which is accompanied by loss of consciousness and convulsions. In this case, the main thing is not to get confused. The patient should be placed on his side and a pillow should be placed under his head. Next, you should place, for example, a pencil or pen in your mouth to prevent biting your tongue. In no case should you restrain the patient's movements (hold him by the arms and legs or press him down with your body), as this will only increase the seizures and the risk of getting a fracture or dislocation.

A common mistake is using ammonia, which can lead to respiratory arrest. If a person has lost their heartbeat or breathing, direct cardiac massage and artificial respiration can help.

The number of people suffering from this terrible and deadly disease is increasing every year. This is facilitated by the modern sedentary lifestyle, as well as unhealthy diet, leading to obesity. Therefore, it is recommended to regularly play sports (spontaneous loads can lead to a jump in blood pressure and cause rupture of blood arteries and veins), lead an active lifestyle and observe the correct diet. Following these simple recommendations will significantly reduce the risk of stroke.

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What is stroke, what types of disorders exist and how each type of pathology is diagnosed

Elderly people are familiar with such a disease, the name of which is ONMK - acute cerebrovascular accident or just a stroke. Almost every older person experienced this ailment on himself. It is very important to understand the causes of stroke and proper treatment of the disease.

What it is?

Stroke is a clinical symptom manifested by sharp disruptions in the normal operation of the existing options of the brain of the head, the duration of which is more than one day.

The main symptoms of stroke are:

1. The inability of the patient's body to move normally;
2. Disorders of the organs responsible for sensitivity;
3. Violations of the proper functioning of the speech apparatus;
4. The inability of the patient to make swallowing movements;
5. Frequent headache;
6. Loss of consciousness.

An unexpectedly appeared violation of the speech apparatus, loss of body sensitivity and problems with coordination of movement disappear over the next day. Then they talk about a transistor ischemic attack. This is not such a dangerous disease as a stroke, but it also applies to stroke.

If the disease refers to disorders in the work of the circulatory system, then it is characterized as "ACV by the type of ischemia." In the case when a specialist confirms bleeding, then the disease has the characteristic of "CVA of hemorrhagic type."

A stroke that ends in stroke is the stage when blood flow to some part of the brain stops. This phenomenon is caused by a decrease in the tone of the walls of the arteries of the brain and is accompanied by a disorder of the neurological system, which is a consequence of the destruction of part of the nerve tissue.

ONMK - code according to ICD-10

In the tenth international classification of diseases, ACVA has several codes that differ from each other according to the disorders that caused the disease.

Prevention and therapy of this disease are considered at the state level, since ACVA is fatal in one third of cases. Sixty percent of patients who have had the disease turn out to be disabled, who cannot do without social assistance.

Causes of ACVA

ACVA, which is related to the ischemic type, develops as a result of existing pathologies in the patient's body.

Such diseases include:

• Hypertonic disease;
• Atherosclerotic vascular disease;
• Myocardial infarction, suffered by the patient earlier;
• Inflammatory disease of the inner lining of the heart;
• Disorder of the rhythm of contractions of the heart muscle;
• Change in the work of the heart valve;
• Inflammatory processes in the walls of blood vessels of a systemic nature;
• Disorder of the tone of blood vessels;
• Expansion and abnormal development of blood vessels;
• Pathology of the circulatory system;
• Blood clots;
• Diabetes.

ACVA occurs not only in the adult population, but also in children. This is due to the fact that the vessels of the child's brain have any abnormalities in their development. A high risk of developing stroke is observed in children who have congenital heart disease.

When stroke occurs, only 30% of children fully recover. About fifty percent have incurable disorders in the neurological system. Twenty percent of cases of development of acute circulatory disorders of the brain in children are fatal.

In what cases can ONMK be suspected?

The diagnosis of stroke is made if the patient has the following disorders in the body:

1. A sharp lack of sensitivity in the limbs;
2. Loss of vision up to blindness;
3. Inability to recognize the opponent's speech;
4. Loss of balance, coordination problems;
5. Very severe headaches;
6. Clouding of consciousness.

An accurate diagnosis can be made only after a diagnosis has been made.

Stages of cerebral infarction

ONMK has several stages of development. Let's consider each of them in more detail.

Ischemic stroke

ACVA of this type is accompanied by a complete cessation of blood flow delivery to specific areas of the brain tissue, which are accompanied by the destruction of brain cells and the termination of the work of its main functions.

Causes of ischemic stroke

ACVA of this type is caused by the obstruction of blood flow to any brain cell. As a result, the normal functioning of the brain stops. Plaque, which is made up of cholesterol, can also interfere with normal blood flow. More than 80% of all diseases are caused by this.

Risk group

ACVA is most often manifested in a population category that has the following pathologies:

• Vascular disorders of an atherosclerotic nature;
• A sharp increase in blood pressure;
• Previous extensive myocardial infarction;
• Stretching an artery;
• Acquired or congenital heart defects;
• Increased blood density caused by diabetes:
• Reduced blood flow rate, which is a consequence of cardiac insufficiency;
• Overweight;
• Transistor ischemic attacks previously suffered by the patient;
• Excessive consumption of products of the alcoholic and tobacco industry;
• Reaching the age of sixty;
• Use of oral contraceptives that can cause blood clots.

Symptoms of the disease

1. Mild headache;
2. Vomiting;
3. High blood pressure over a long period;
4. Increased tone of the neck muscles;
5. From the very beginning, the disease is accompanied by impaired motor function;
6. Disorder in the work of the speech apparatus;
7. In laboratory diagnostics of cerebrospinal fluid, it has a colorless tint;
8. There is no retinal hemorrhage.

Neurologists distinguish several intervals in the development of ischemic stroke according to the severity of the disease:

1. The sharpest. Lasts up to five days;
2. Spicy. The duration is 21 days;
3. Early recovery. From the moment the elimination of acute symptoms takes six months;
4. Recovery at a later stage. The rehabilitation period lasts for two years;
5. Elimination of traces. More than two years.

In addition to general symptoms, ischemic cerebral stroke is characterized by local symptoms. It depends on the zone in which the disease occurred.

And so, if the internal carotid artery is affected, then the following symptoms appear:

• Disorder of the visual system in the side where the vessel was blocked;
• The sensitivity of the limbs disappears from the opposite side of the lesion focus of the disease;
• In the same area, muscle tissue paralysis occurs;
• Disorders in the work of the speech apparatus are observed;
• The inability to realize your illness;
• Body orientation problems;
• Loss of visual field.

With narrowing of the artery of the spine, other symptoms are noticeable:

• Decreased hearing;
• Twitching of the pupils when moving in the opposite direction;
• Objects look double.

If the lesion happened at the site of combination with an unpaired blood vessel, then the symptomatology manifests itself in a more severe form:

• Severe disturbances in the work of the locomotor system;
• Problems with gesturing;
• Abrupt articulation of speech;
• Disorder in the joint work of the motor apparatus of the body and limbs;
• Malfunctions of the respiratory system;
• Violation of blood pressure.

In case of damage to the anterior cerebral artery:

• Loss of sensitivity in the opposite side, usually in the leg area;
• Slowness in movement;
• Increased tone of muscle-flexor tissue;
• Lack of speech;
• The patient cannot stand and walk.

If failures interfere with the normal patency of the middle cerebral artery:

• The consequence of a complete blockage of the main trunk is a state of severe coma;
• In half of the body, there is a loss of sensitivity;
• The locomotor system refuses;
• The inability to fix the gaze on the subject;
• Fields of vision drop out;
• There is a failure of the speech apparatus;
• The patient is unable to distinguish the right limb from the opposite.

When the patency of the posterior cerebral artery is impaired, the following clinical picture is observed:

• Loss of vision in one or both eyes;
• Doubling of objects in the eyes;
• Lack of joint movement of the eyeballs;
• The patient has convulsive movements;
• Severe tremor is characteristic;
• Inability to swallow food and saliva normally;
• Paralysis of the body on one side or on both sides at once;
• Disorders in the respiratory system;
• Coma of the brain.

Blockage of the optic-geniculate artery is accompanied by the following symptoms:

• Lack of tactile sensations on the opposite side of the face and body;
• If you touch the patient's skin, then he experiences severe pain;
• Wrong perception of light and knocking;
• The forearms and shoulder joints are flexed. The fingers are also bent at the base.

The lesion in the area of ​​the visual hillock is characterized by the following symptoms:

• The patient's movements have a wide range;
• There is a strong tremor;
• Loss of coordination occurs;
• Half of the body loses sensitivity;
• Excessive sweating is characteristic;
• Bedsores develop.

The most severe case of ACVA is the process of breaking through an intracerebral hematoma. Hemorrhage occurs in the cerebrospinal fluid pathways, fills the cerebral stomachs with blood. This ailment is called "ventricular tamponade".

This case of acute cerebrovascular accident is the most severe and in almost all cases is fatal. The explanation for this lies in the unobstructed flow of blood to the patient's brain.

Treatment of stroke by ischemic type

The above symptoms may appear unexpectedly in a loved one. It is very important to provide first aid to the patient.

After calling an ambulance, it is necessary to alleviate the patient's condition using the following techniques:

1. Put the patient on the side so that the vomiting leaves the victim's mouth without hindrance;
2. The head should be slightly raised;
3. If you have a tonometer, then you need to measure your blood pressure. If a sharp increase in pressure to critical values ​​is noticed, then a drug should be placed under the patient's tongue to reduce it;
4. Provide the patient with an amount of fresh air;
5. Free the patient's neck from any compressive things.

Inpatient treatment

After arriving at a medical facility, the victim is placed in an intensive care unit. Further, the patient is assigned a special diet, in which the emphasis is placed on the balance of all the necessary trace elements. Nutrition is adjusted so that fatty, spicy, salty foods are not observed in the diet.

Mayonnaise and other condiments should also be avoided. Vegetables and fruits are limited only during the acute stage of the disease. If the patient's consciousness is absent, then food intake is carried out through a medical probe no earlier than two days later.

After confirmation of CVA, inpatient treatment continues for a month. The consequences after transferring this ailment are extremely severe.

A strong decrease in strength in the muscle tissue on the opposite side of the brain, the area of ​​which has been affected. A certain category of patients practically learns to walk again and perform normal movements;

Disorders in the work of facial muscles. The decrease in strength occurs only in the area of ​​the mouth, cheeks and lips. The patient is unable to properly eat and drink;

Disrupted work of the vocal apparatus is quite common. It is caused by damage to the speech center in the human brain. The patient either completely loses speech, or does not perceive the words of another person;

Movement coordination disorder is caused by damage to the parts of the central nervous system that are responsible for the normal functioning of the human motor system. In severe cases, violations can persist for several months;

Failures in the work of the visual system are of a different nature and depend on the size and location of the focus of the stroke. Usually they are expressed in the loss of visual fields;

Sensory impairment is expressed in the loss of pain, feeling of warmth and cold.

Rehabilitation

A very important stage on the path of recovery after stroke.

Quality therapy includes the following categories of treatment:

1. Physiotherapy. It is necessary to return the patient to normal movement of the limbs. The set of exercises is selected by the attending physician;
2. Visit to a speech therapist. It is prescribed if the patient has speech and swallowing disorders;
3. Physiotherapy. The most affordable type of therapy, which is located in every clinic;
4. Medication therapy. The main stage in the recovery process. Drugs mitigate complications after illness and prevent the risk of relapse;
5. Training for the mind. It is advisable for the patient to read as much literature as possible, memorize poetry or excerpts of works.

Stroke by hemorrhagic type

The components that provide nutritional action, which include oxygen, enter the brain through the carotid arteries. Located in the cranial box, they form a network of vessels, which is the root of the blood supply to the central nervous system. When the destruction of the artery tissue occurs, then the flow of blood rushes to the brain.

Causes of occurrence

Hemorrhagic stroke occurs in the case of cerebral hemorrhage from a vessel whose integrity has been compromised. As a result, a hematoma occurs in the patient's brain, which is limited to the brain tissue. Also, blood from a ruptured vessel can enter the area surrounding the brain.

Risk group

Particular attention should be paid to the state of your health of the following category of citizens:

• Suffering from congenital dilation of blood vessels;
• Having anomalies in the development of arteries and veins;
• Suffering from inflammatory diseases of the walls of blood vessels;
• With pathologies of connective tissues of a systemic nature;
• Having lesions of blood vessels, accompanied by a violation of protein metabolism;
• Abuse of drugs that stimulate the nervous system.

Symptoms

1. Acute headache;
2. Constant gagging;
3. Frequent loss of consciousness over a long period;
4. In almost all cases, there is an increase in blood pressure;
5. Increasing sensations of weakness in the limbs;
6. Disorder in the work of the organs responsible for sensitivity or complete loss of sensitivity;
7. Violation of the motor system;
8. Disorder of the visual system;
9. Strong nervous excitement;
10. When tested, a small amount of blood is observed in the cerebrospinal fluid;

Treatment of stroke by hemorrhagic type

Drug therapy consists in the use of drugs, the action of which is aimed at stopping bleeding, reducing the size of the cerebral edema, and calming the nervous system. Antibiotics and beta blockers are used.

Medicines can cause a relapse of stroke, so it is advisable to eliminate the problem through surgery. First of all, the neurosurgeon removes the lesion, and then eliminates the malfunction in the vessel.

Reversibility of pathology

During diagnostic studies, it is essential whether the symptomatology of stroke is reversible. When the stage is reversible, the brain cells exist in the paralysis phase, but their integrity and full-fledged work are not disturbed.

If the stage is irreversible, then the brain cells have died and cannot be restored in any way. This area is called the "ischemic zone". But therapeutic treatment is possible in this case.

Its meaning is to provide neurons with all nutrients in the ischemic zone. With proper treatment, cell functions can be partially reanimated.

It was found that a person does not use all the resources of his body in the process of his life, including not all brain cells are involved. Cells that are not involved in work can replace the killed cells and ensure their full functioning. The process is rather slow, so full rehabilitation continues for three years.

Transistor ischemic attack (TIA)

This disease is also a stroke, but unlike ischemic and hemorrhagic stroke, it is temporary. For a certain period of time, there is a sharp disturbance of blood flow in the large vessels of the brain, as a result of which its cells suffer from a lack of oxygen and nutrients. Symptoms of TIA, a transistorized ischemic attack, last for 24 hours and are similar to those of a stroke.

If more than 24 hours have passed, but the disease has not receded, then most likely an ischemic or hemorrhagic stroke has occurred.

Symptoms

Consider the symptoms of transistor ischemic attack:

• There is a decrease in sensitivity in one of the sides of the face, body, lower or upper limbs;
• Weakness in the body that is mild to moderate;
• Violations in the work of the speech apparatus, up to the complete absence of speech or problems with understanding the words of the opponent;
• Dizziness and lack of coordination;
• Sudden noise in the ears and head;
• Headache and heaviness.

These symptoms appear abruptly and disappear after 3-4 hours. The deadline that distinguishes a transistor ischemic attack from a stroke is no more than a day.

What diseases can cause TIA?

TIA can be caused by the following conditions:

1. Persistent increase in blood pressure, which is chronic;
2. Chronic vascular disease of the brain;
3. Changes in blood clotting;
4. A sudden drop in blood pressure;
5. Impossibility of normal blood flow through the artery caused by a mechanical obstacle;
6. Pathology of the structure of the vessels of the brain.

Transistor ischemic attack can and should be treated! Despite the fact that her symptoms go away rather quickly, this ailment already signals a malfunction in the body and, in case of relapse, can turn into a stroke!

Risk group

• Those who consume an excessive amount of products of the tobacco and alcohol industry;
• Suffering from an increase in blood pressure of a chronic nature;
• Have high blood cholesterol levels;
• Diabetes sufferers;
• Overweight;
• Leading a sedentary lifestyle.

A transistor ischemic attack is no less dangerous than a stroke. Up to 8% of TIA patients in the future suffer from a stroke that occurs within a month after the attack. In 12% of patients, stroke occurs within a year and in 29% within the next five years.

Treatment of transistor ischemic attack

It is carried out in a hospital.

Diagnostic tests include the following procedures:

1. Visit to a cardiologist, angiologist and ophthalmologist. The patient is prescribed a consultation with a medical psychologist;
2. For laboratory analysis, the patient must pass a general blood and urine test, as well as blood for biochemical analysis;
3. Electrocardiography;
4. Computed tomography of the brain;
5. X-rays of light;
6. Constant blood pressure check.

The victim is allowed to go home only if the recurrence of TIA is excluded or the patient has the opportunity to be immediately hospitalized in the event of a second attack.

Treatment for transistor ischemic attack consists of taking the following oral medications:

• The action of which is aimed at thinning the blood;
• Vasodilatation agents;
• Lowering blood cholesterol levels;
• Aimed at normalizing blood pressure.

It is good to combine drug therapy with balneotherapy and physiotherapy.

Prophylaxis

To avoid the occurrence and recurrence of a transistor ischemic attack, a set of preventive measures should be followed:

1. Go in for sports, having previously drawn up a lesson plan with your specialist;
2. Correct your diet by reducing the amount of fatty, salty and spicy foods;
3. Reduce the use of alcoholic beverages and tobacco;
4. Monitor your body weight.

Survey algorithm

It is possible to diagnose stroke by the characteristic symptoms, but in order to determine the degree of the course of the disease, to which type of stroke it belongs,

It is necessary to undergo a series of diagnostic tests.

Examination by a specialist immediately after the patient is admitted to a medical institution;

Taking blood for laboratory analysis, in order to assess the state of glucose levels, clotting, enzymes;

Computed tomography in this case allows you to get more complete information about the disease. In the first 24 hours after the ischemic disorder, it is not possible to find out the localization of the affected area.

This problem can be solved by performing magnetic resonance imaging;

Angiography of the cerebral vessels helps to determine with reliable accuracy the area where the lesion or the level of narrowness of the artery has occurred. With this study, you can diagnose aneurysm and pathological connection between the veins and arteries of the brain.

But the results obtained do not allow to correctly estimate the volume of destruction of the nerve tissue. The solution to this problem is to combine vascular angiography with other diagnostic methods;

The collection of cerebrospinal fluid for laboratory tests is a threat to the patient's life, but this test allows you to determine what type of stroke belongs to.

This diagnostic method is used mainly in medical institutions that lack more advanced equipment.

Forecast

A favorable outcome after the disease has a category of citizens who have experienced a small form of stroke. With minor restrictions, these patients can normalize their vital functions.

Statistics show that 40% of deaths occur within the first month after illness. 70% show signs of disability in the first month. Over the next 6 months, 40% become disabled. After two years, signs of disability are noticeable in 30% of patients.

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 therapy of this pathology.

Acute ischemic stroke

Stroke damages and kills neurons in a specific area of ​​the brain. ACVA by ischemic type causes neurological disorders that do not disappear after a day. A person can paralyze one half of the body, speech is severely impaired. He may partially or completely lose sight. This happens if the arteries supplying blood to the brain cease to function due to a blood clot or rupture of blood vessels. Without receiving it, the tissues of the organ begin to die off.

When a person develops an ischemic stroke, it changes dramatically. He becomes less active, behaves lost. Facial distortion is possible. If you ask the patient to smile, then instead of the correct smile there will be only a specific twisted grimace. Motor functions are impaired, it is difficult for the patient to navigate in space. It is difficult for a person to answer the most common questions. The limbs stop obeying him.

Acute IUD 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 occur intermittently throughout the day. This often happens at night. Stroke is one of the main reasons why young able-bodied people become disabled. The extent to which a person can get rid of the neurological disorders described above depends on how quickly the disease is detected and the treatment tactics are correctly chosen.

Basic stroke therapy

It got its name because it is applied to all variants of acute cerebrovascular accidents. Basic treatment is directed to keep the patient alive until the type of stroke is identified, and begins immediately after he is admitted to the hospital. After it, when the nature of the disease is established, differentiated therapy is carried out. Basic treatment is a complex of specialized measures, the main goals of which are as follows:

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

Thrombolytic therapy for stroke

Its second name is thrombolysis. It is currently the only truly effective method to bring a person back to life after a stroke. Thrombolytic treatment is aimed at restoring blood flow in a vessel that has suffered from a blood clot or an atherosclerotic plaque in the acute period. This helps protect brain tissue from destruction and increases 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 CCD. The procedure is effective only when 6 hours have not passed since the formation of the thrombus. 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. A drug to dissolve a blood clot is injected directly into the canal of the damaged artery, and not just into a vein, thanks 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 disease;
• recent surgery;
• acute renal failure;
• pregnancy.

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

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

Medicines to improve brain circulation

Ischemic cerebral stroke is treated with the following medications:

1. Piracetam. It is prescribed under almost any conditions, it enhances cerebral blood flow.
2. Aminalon. A medicine for the normalization of blood microcirculation in the brain, inhibition of neurological pathologies. It will help you get out of the acute period faster.
3. Phenotropil. Enhances blood flow, helps improve memory and concentration.
4. Vinpocetine. Vasoactive drug to improve blood circulation.
5. Phenibut. A drug for stimulating brain activity.
6. Glycine. Not only improves blood circulation in the brain, but also contributes to the early termination of the acute period, helps to fight depression.
7. Vasobral. 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 a therapeutic massage is prescribed.
10. Pentoxifylline.
11. Instenon. Improves cerebral circulation.
12. Gliatilin. Stroke medicine is prescribed in the acute period. If the patient is in a coma in the intensive care unit, then the remedy is prescribed.
13. Calcium blockers.

Antiplatelet agents for stroke

These drugs start 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 CCD. It should be noted that the feasibility of using antiplatelet agents in 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 agents have side effects, therefore, 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, rash, but side effects are very rare.
3. Sulfinpyrazone leads to various complications. As a result of taking it, gastritis may occur, kidney stones appear. Rash and anemia are common.
4. Disorders of the bowel may occur from ticlopidine.

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 drugs is aimed at preventing the growth of blood clots and preventing neurological pathologies from progressing. More drugs for blood clotting are prescribed to prevent recurrent stroke. They have a number of contraindications, therefore 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 a muscle are also acceptable, but they are not nearly as effective. Along with it, and even at the rehabilitation stage, it is necessary to take indirect anticoagulants: Dikumarin, Pelentan, Sinkumar, Fenilin. They are all available in tablets. The dosage is calculated separately for each patient. The admission period can be up to several years.

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