Ischemic cerebral stroke: prognosis and consequences

Cerebral stroke, or "brainstorm" - the "killer" number two in the overall mortality of the world's population: 25% of men and 39% of women die through his fault.

More often, in four cases out of five, it has an ischemic nature, that is, the blood supply to the brain is disrupted by the blockage of the arteries with a thrombus or embolus.

The brain is such a thin and demanding body structure that, at a weight of 2% of body weight, it consumes 1/5 of the volume of incoming oxygen and 17% of the total glucose. Even a short-term disruption of the blood supply to a small area of ​​the brain does not pass without a trace. If the ischemia lasts more than 5 minutes, irreversible changes occur in the cerebral cortex. When the focus is located in the middle brain, cells die within 10 minutes of ischemia, and in oblong - in 25 minutes.

What are the consequences and prognosis of cerebral ischemic stroke - read this article.

Prognosis of the disease

We should talk about three outcomes of a stroke: recovery, disability and mortality, both of which can be considered favorable. Within a month after an ischemic stroke, every third or fourth patient dies. By the end of the first year, lethality increases to 50% in rural areas and up to 40% in major cities.

Stroke is the first cause of persistent disability in the structure of Russia's disability. Only one in five patients who underwent a cerebral vascular accident can return to work, and no more than 10% recover completely.

Among the survivors of half the people there is a repeated episode within five years.

The fate of a particular patient depends on the localization and size of the focus of ischemia, the state of anastomoses of cerebral vessels and concomitant pathology. It is difficult to make an individual forecast even after the most detailed survey. If the stroke zone is localized in the region of the pyramidal tract, the motor disorders will be more pronounced if speech disturbances occur in the cortical speech areas of Brok and Wernicke.

However, there are general trends that are statistically reliable. For example, it is known that some factors make the forecast heavier:

1. Location. It is known that urban residents suffer from a stroke much more often than rural people: the incidence of the disease is respectively 3 and, the case per 1000 population. However, the death rate from stroke in the region is higher than in the city, which emphasizes the role of timely provision of qualified medical care.

1. Repeated strokes. In 3/4 cases, the stroke develops primarily, in 25% - again. To predict the secondary stroke, accurate scales of risk assessment have been developed, but the forecast is much heavier.

1. Elderly age. In half the cases the disease develops at the age of 70 years and older, the mortality in such patients is also significantly higher than in the general population. The prediction of speech recovery and complex movements is usually also much harder.

1. Personality changes. At any stroke there are cognitive and emotional-volitional violations. By the degree of their severity and the rate of reverse development, one can also judge the prognosis of the disease.

The positive outcome of the disease is affected by such factors as earlier medical care, early activation and the beginning of recovery activities, as well as the spontaneous restoration of lost functions, both speech and motor.

For a more accurate forecast, scales of individual risk assessment have been developed. Unfortunately, they are not able to predict the first episode of a stroke. The most common cause of ischemia is embolism of the cerebral artery. It is almost impossible to prevent plaque or clot lag breakage and clotting of the vessel, as well as to predict at what point this will happen.

Methods for assessing overall risk factors show good results in terms of prevention of secondary episodes. A fairly accurate prediction of the stroke is given by the AVCD scale in patients who have already transferred transient ischemic attacks (TIA). It includes criteria such as age, blood pressure, clinical symptoms and their duration, as well as the presence or absence of diabetes mellitus.

Consequences of Ischemic Stroke

In Europe, disability after stroke is 360 people per 100 000 population. In Russia, this data is much higher.

With such high rates of disability, it is important to know what consequences are expected after a vascular catastrophe of the brain and how to accelerate recovery.

Degree of disability

The restoration of lost functions depends on the duration of ischemia and the death of nerve cells:

1. Complete recovery after a stroke occurs only in 10% of cases and is possible with temporary inactivation of brain structures that are not accompanied by their damage.
2. Compensation of functions: occurs when the system of interrelations between neurons is restructured.
3. Adaptation: adaptation to a permanent motor defect with the help of prostheses and other mechanisms.

Classification of post-stroke consequences

By the level of changes are distinguished:

• focal (due to hypoxia in certain areas of the brain);
• cerebral (universal reaction of the brain in the form of edema);
• meningeal (when involved in the process of the meninges);
• extracerebral disorders (changes in other organs).

With strokes, only focal symptomatology may appear. Ischemic processes are always characterized by its predominance over other symptoms. There are situations when isolated general cerebral or meningeal disorders occur. In people with a high risk of the disease, this may indicate severe circulatory disorders.

Depending on the stage of the stroke, the consequences may be

• early, developed into the sharpest (up to 5 days) and acute period (up to the 21st day);
• late, occurred in the early (up to 6 months) or late (up to 2 years) recovery period;
• persistent residual phenomena, which for greater strokes persist for more than 2 years.

Focal effects

Omitting the angle of the mouth in combination with weakness in the limbs is a characteristic sign of a stroke.

Focal symptomatology is completely dependent on the localization of the focus of ischemia. The most frequent are consequences in the form of violations of motor and speech function, the most formidable are swallowing disorders, and infrequent visual impairments.

Recovery after a stroke requires tremendous effort both from the patient and from his relatives, Therefore, negative changes in the personality, which are sharply manifested during the rehabilitation period, are considered as the psychologically most heavy.

1. Violations of motor activity

Disorders in the form of paresis (weakening of the volume of voluntary movements) and paralysis (complete cessation) by the end of the acute period are observed in 80-90% of patients. In 2/3, violations of mild to moderate motion predominate on the one hand (unilateral hemiparesis).

Hemiparesis is usually combined with disorders of sensitivity, speech or vision. Very rarely there is an isolated impairment of motor function.

Volume and strength of movements usually begin to recover already in the first week after a stroke. Full recovery takes about six months, and complex motor skills are formed anew within 1-2 years.

The prognosis of restoring motor function deteriorates if there are no positive changes during the first month after the stroke. On the contrary, the earlier the spontaneous restoration of movements begins, the more optimistic the forecast.

1. Trophic disorders

During the second month of the disease, 15% of patients develop arthropathies - joint diseases due to disruption of their trophism. More often, changes occur in the joints of the upper limb on the side of the lesion: fingers, wrist and elbow joint. Sometimes similar symptoms occur in the joints of the lower limb. Due to severe pain, movement in these joints can be severely limited, which contributes to the formation of contractures in the future. Sometimes muscle atrophy is formed, the propensity to form bedsores increases.

1. Violations of speech

In patients after a stroke, not only speech functions suffer, but often they do not understand the meaning of words and forget the names of objects.

Speech disorders occur in almost half of stroke patients, and are combined with a lesion in the motor function. They are manifested as:

• Dysarthria - Pronunciation and articulation disorders due to the limitation of the mobility of the speech organs;
• aphasia - speech disorders in the form of "forgetting" the names of objects, violation of understanding words or complex phrases, etc .;
• alphabetic agnosia, or violation of the recognition of written speech, difficulties in reading and writing.

The primary restoration of speech occurs during the first half of the year. To restore the initial level of communication, rehabilitation may be required for 2-3 years after the stroke.

1. Bulbar and pseudobulbar syndrome

When the focus of ischemia is localized in the bulbar section of the brain stem, there is a lesion of the cranial-cerebral nuclei responsible for the swallowing process. Dysphagia (impaired swallowing) is one of the most dangerous consequences of a stroke. A liquid or food can get into the airway rather than into the esophagus, which causes asphyxia or pneumonia. If the patient stops eating due to a violation of swallowing, there are dystrophic disorders.

In addition to dysphagia, with bulbar syndrome, the following disorders occur:

• dysarthria;
• dysphonia - changes in the voice in the form of nasal or hoarseness;
• prolapse of pharyngeal reflex;
• sagging on one side of the palatine curtain;
• salivation.

Pseudobulbar syndrome occurs when the focus of ischemia in the supranuclear structures of the brainstem is localized. In addition to dysphagia, dysarthria and dysphoria, it can be manifested by violent laughter or crying, strengthening reflexes from the pharynx and the soft palate.

1. Visual disorders

If the visual pathway is affected, the following can occur:

• scotoma - loss of visual fields;
• hemianopsia - bilateral blindness of the same or different halves of the fields of vision (right and left or internal and external);
• amavroz - partial or total blindness due to damage to the optic nerve or retina;
• photopsy - flickering of moving spots or dots ("flies") in front of the eyes in the absence of pathology of the eye organ.

1. Personality changes

Focal lesions of the brain can be accompanied by changes in cognitive mental functions. More often the following violations are observed:

• difficulty orientation in a changing environment;
• decreased attention;
• slowing down of mental processes;
• significant memory impairment;
• astheno-depressive syndrome.

Post-stroke depression often catches the patient's relatives who are not ready for such consequences. However, this disorder, like others, is treatable. Sometimes there are causeless changes of mood, possible aggression, negativism, apathy.

In 7-15% of patients, epilepsy appears due to a stroke.

Cerebral infringements

The intensity of cerebral consequences can fluctuate from the sensations of "fog" in the head to the coma. As a result of cerebral edema, headache, nausea, vomiting occur. May disturb soreness along the root of the spinal nerves.

Meningeal disorders

Meningeal symptoms appear some time after a stroke, more often in the 2-3 weeks, when involved in the process of the meninges. The most commonly determined strain of the back muscles of the neck, the positive symptoms of Kernig and Brudzinsky.

Extracerebral disorders

After severe strokes at the end of the first and beginning of the second week, there is a syndrome of multiple organ failure, which determines the outcome of the disease. This is called the inability of 2 or more functional systems of the body to maintain the state of homeostasis in critical situations.

All patients experience acute disruption of the respiratory system, 2/3 have cardiovascular system, 60% have gastrointestinal mucosa, and 46% have kidneys.

The cause of deaths after a stroke are the following extracerebral disorders:

• thromboembolism of the pulmonary artery - in 20% of cases
• pneumonia due to dysphagia - in 5%;
• acute myocardial infarction - in 4%;
• acute renal failure - in 4%.

Persistent residual phenomena

In addition to restoring impaired functions, secondary post-stroke complications may develop in the post-stroke period.

In connection with forced long-term bed rest, thrombophlebitis of the extremities, PE, stagnant processes in the lungs, and pressure sores may appear.

Speech violations can lead to a "telegraphic" communication style.

Against the background of the restoration of the volume and strength of movements, a frequent complication is spasticity. With any movements in the joints, the patient has to overcome muscle tension. The cause of this is the disinhibition of the tonic dilatation reflex. The spastic tone of the muscles prevents rehabilitative programs and contributes to the formation of persistent contractures.

Muscular dystonia that occurs after a stroke is characterized by the following features:

• increases with passive stretching of the muscles;
• Increases with increasing speed of movement;
• depends on the nature and intensity of the load, the position of the limb;
• its degree varies during the day under the influence of external and internal factors.

In addition to spasticity, impaired motor activity may be associated with the development of secondary muscle atrophy. Thus, contractures are the most frequent consequences of a stroke.

Dystonia of the muscles of the spine can be accompanied by complications in the form of radicular syndrome, pain in the thoracic or lumbar region.

In the early recovery period, 60-80% of patients experience complications in the form of falls. Their risk increases with the following violations:

• coordination and balance;
• musculo-articular feeling;
• view;
• attention deficit;
• hypotension of the muscles of the paretic limb;
• with a general asthenia, which may increase under the influence of certain drugs;
• Orthostatic hypotension - a sharp decrease in pressure during the transition from the horizontal to the vertical state.

Many factors influence the prognosis of ischemic stroke. Survival is already worth considering as a favorable outcome.

Recovery after the disease is no less important task. How rehabilitation will take place and its results directly depend on the will and patience of the patient's family and their assistance in implementing medical rehabilitation programs.