Spinal stroke is an acute impairment of blood circulation in the spinal cord. This pathology is much less common than a circulatory disorder in the brain, but it does not become less dangerous from this. A spinal stroke can be ischemic and hemorrhagic. This is a serious disease, requiring mandatory and fastest hospitalization, a fairly long treatment. In the absence of medical care, spinal stroke can lead to loss of ability to work and disability.
In order to timely contact a specialist and begin timely treatment of a spinal stroke, it is extremely important to know the symptoms of the disease and imagine the reasons for the development of this pathology.
- 1General information on blood supply to the spinal cord
- 3.1Ischemic stroke of the spinal cord
- 3.2Hemorrhagic Stroke of the Spinal Cord
General information on blood supply to the spinal cord
Blood supply of the spinal cord is carried out from two pools: vertebral-subclavian and aortic. The vertebral-subclavian pool feeds the spinal cord in the upper parts: the cervical segments and the thoracic segments to Th3 (third thoracic segment). Aortic blood supply to thoracic segments from Th4 and below, lumbar, sacrococcygeal segments. The spinal arteries that form anterior spinal artery and two posterior spinal arteries running along the entire spinal cord.
Blood supply of the spinal cord is very variable, the number of radicular-spinal arteries varies from 5 to 16. The largest anterior radicular spinal artery (up to 2 mm in diameter) is called the artery of the lumbar thickening, or the artery of Adamkiewicz. Turning it off leads to the development of a characteristic clinical picture with severe symptoms. In a third of cases, one artery of Adamkiewicz feeds the entire lower part of the spinal cord, beginning with the 8th-10th thoracic segment. In some cases, except for the artery of the lumbar thickening, there are: a small artery entering with one of the lower pectorals, and the artery entering with V lumbar or I sacral spine, supplying the cone and the epiconus of the spinal cord - the artery of the Deprozh-Gotteron.
The system of the anterior spinal artery vascularizes 4/5 of the diameter of the spinal cord: anterior and lateral horns, bases of hindbones, clark pillars, lateral and anterior columns and ventral sections of posterior columns. The posterior spinal arteries supply the posterior columns and the apex of the hindbusts. Between systems there are anastomoses (natural connections of organs).
Knowledge of the angioarchitectonics (structure) of the spinal cord is necessary for understanding the mechanisms of circulatory disorders and clinical diagnosis.
There are many causes that lead to a spinal cord blood flow disorder. Most patients develop ischemic brain damage (myelo-ischemia) and only occasionally - hemorrhage (hematomia).
All causes can be classified as follows.
Primary vascular lesions:when the basis of the pathology of the vessel itself.
- General diseases - atherosclerosis, hypertension, acute heart failure, myocardial infarction, etc .;
- Vascular pathology and vascular malformations - aneurysms, stenoses, thromboses, embolisms, kinks and vascular loops, varicosity;
- Vasculitis - infectious-allergic, with syphilis, HIV infection.
Secondary vascular lesions:when the vessels are supported by a process from the outside.
- Diseases of the spine - osteochondrosis, spondylolisthesis, tuberculous spondylitis, congenital synostosis;
- Diseases of the membranes of the spinal cord - arachnoiditis, leptopachymeningitis;
- Tumors of the spinal cord and spine.
- Injuries (including operative interventions - radiculotomy with the intersection of the radicular-spinal artery, aortic plasty);
- Diseases of the blood;
- Endocrine diseases.
Of course, many patients are simultaneously experiencing several factors of the disease, which increases the risk of its occurrence. Whatever the reason was not a source of circulatory disturbance, as a result, the brain tissue that did not receive nutrition or was destroyed as a result of impregnation (compression) with blood suffers. Clinically, this manifests itself as a violation of the functions of the affected area, on which neurological diagnostics is based.
A spinal stroke can be of two types:
- ischemic - spinal cord infarction;
- hemorrhagic - hemorrhage into the brain is called hematomyelia, hemorrhage under the membranes of the brain - haematorexis, epidural hematoma.
Ischemic stroke of the spinal cord
Equally often develops in men, and in women. More often this disease affects people older than 50 years, since the main cause is the pathology of the spine.
During the process, several stages are distinguished:
- The stage of distant and close precursors - a few days, weeks before the development of a patient's infarction begin to disturb motor disorders in the form of a short-term and transient weakness in the legs or hands (this depends on which vessel is affected - from the vertebral-subclavian or from the aortic basin). In the same limbs, sensitive disorders are also revealed: numbness, a feeling of crawling, chilliness, burning, just unpleasant sensations in the muscles. Sometimes there may be an imperative urge to urinate, a delay or an increase in urination. May disturb the pain in the spine, transient to the upper or lower limbs, associated with a malnutrition of sensitive roots and membranes of the spinal cord. With the development of stroke, pain passes, which is associated with a break in the passage of pain impulses in the affected area. Predisposing factors are often identified: alcohol use, physical overstrain, overheating, sudden movements in the spine.
- Stage of the development of a heart attack - within a few minutes or hours develop a pronounced muscular weakness (paresis) in the limbs, loss of sensitivity in these limbs, there are pronounced violations of the pelvic organs. The pain syndrome ceases (the causes are described above). At the time of development of a stroke, symptoms of brain damage (reflex) are also possible: headache, dizziness, fainting, nausea, general weakness. The clinic of the affected area of the brain depends on the location of the affected vessel.
- The stage of stabilization and reverse development - the symptoms cease to build up and regress against a background of adequate treatment.
- The stage of residual phenomena is the residual phenomena of a stroke.
Depending on which area of the brain is affected, the following clinical syndromes are distinguished:
- when the anterior spinal artery is injured in the uppermost areas - tetraparesis (all 4 limbs) by spastic type, violation pain and temperature sensitivity in all limbs, signs of damage to the 5th and 12th pairs of cranial nerves;
- when the anterior spinal artery is injured in the region of the upper cervical segments - the same as in the previous paragraph, but without lesion of the cranial nerves;
- when the anterior spinal artery is injured in the area of the cross of the pyramids - tercial hemiplegia: paresis of the arm on the side of the hearth and legs on the opposite side;
- Subalburn syndrome Opalsky - on the side of the focus paresis of the extremities, impaired sensation on the face, ataxia, sometimes Claude-Bernard-Horner syndrome (ptosis, miosis, enophthalmus). On the opposite side - a violation of surface sensitivity on the limbs and trunk;
- syndrome by type of amyotrophic lateral sclerosis - peripheral or mixed paresis of upper extremities, spastic lower limbs, involuntary jerking of the muscles of the shoulder girdle;
- syndrome Persononej-Turner - the expressed pains in the upper parts of the hands, followed by the development of paralysis. With the development of paralysis, pain goes away;
- syndrome of anterior ischemic polyomyelopathy - peripheral paresis of one or both arms;
- ischemic pseudosergeomyelia syndrome - segmental disorders of surface sensitivity and light paresis of muscles;
- ischemia syndrome of the marginal zone of anterior and lateral canals - spastic paresis of extremities, cerebellar ataxia, slight decrease in sensitivity;
- syndrome of the defeat of the upper additional radicular-spinal artery (middle thoracic segments) - spastic paresis of the legs, violation of pain and temperature sensitivity from the level of the nipples and below, impaired urination by the type of delay;
- Braun-Secar syndrome - paresis in one limb or on one half of the body (ie, for example, in the right arm and leg), violation of pain and temperature sensitivity on the other side;
- pathology of the artery of Adamkiewicz - paresis of both legs, violation of all kinds of sensitivity from the lower thoracic segments, dysfunction of the pelvic organs. Rapid development of pressure sores;
- syndrome of paralyzing sciatica - with lesion of the lower additional radicular-spinal artery (Deproge-Gotteron artery). Usually develops against a background of long lumbosacral radiculitis. It manifests itself in the form of paralysis of the calf muscles with drooping of the foot. Pain syndrome with the development of paresis disappears. Also, there are violations of sensitivity from the level of lumbar or sacral segments. When examined, no Achilles reflexes are found;
- cone defect syndrome (lower sacral segments) - paralysis does not occur. There are disorders of the function of the pelvic organs - incontinence of urine and feces. Patients do not feel desires, do not feel the passage of urine and feces;
- pathology of the posterior spinal artery (Williamson's syndrome) - develops a violation of deep sensitivity in the extremities (with a sensitive ataxia) and moderate paresis in these extremities.
A large variability in the structure of the spinal cord system creates difficulties in diagnosing the lesion, but a competent specialist can always make the correct diagnosis.
Hemorrhagic Stroke of the Spinal Cord
With a hemorrhage into the thickness of the substance of the spinal cord (hematomielia), there is acute shingling pain in the trunk with the simultaneous development of paralysis in one or several limbs. Paralysis is often peripheral (flaccid) in nature. In these extremities, there is a disturbance of pain and temperature sensitivity. With massive hemorrhages, tetraparesis may develop with impaired sensitivity and functions of pelvic organs. Combinations of clinical symptoms can be very different, as with ischemic stroke. A large role is played by the size of the hematoma: small ones can resolve, leaving no signs after treatment; large always have residual effects.
Hematorachis is another type of hemorrhagic stroke, quite rare. In this case, a hemorrhage occurs in the subarachnoid space of the spinal cord. More often the cause is the rupture of an abnormal vessel (aneurysm, malformation), trauma of the spinal cord or spine. After the provoking factor develops a pronounced pain syndrome along the course of the spine or shingles. Pain can be a shooting, pulsating, "dagger", held for several days or even weeks. At the time of hemorrhage, there may be general cerebral symptoms: headache, nausea, vomiting, dizziness, impaired consciousness by type of stunning. There are some symptoms of irritation of the meninges: the Kernig symptom is more pronounced, but there is no stiff neck muscles at all. Symptoms of damage to the substance of the spinal cord are either absent altogether, or appear later and have a moderately pronounced character.
Epidural hematoma is characterized by a sharp local pain in the spine in combination with root pains and slowly growing symptoms of compression of the spinal cord. Local pain is the same, is prone to recurrence, remission from several days to several weeks.
The tactics of treatment are determined individually after an accurate diagnosis of the nature and localization of the process. For example, if the cause of a stroke is a severe osteochondrosis with a herniated disc, a vascular anomaly or a tumor, then it is worth considering the possibility of surgical treatment.
For the treatment of ischemic stroke of the spinal cord are used:
- anticoagulants and antiaggregants - heparin, fractiparin, aspirin, plavix, clopidogrel, quarantil (dipyridamole), trental;
- vasoactive drugs - cavinton, pentoxifylline, oxybral, nicergoline, instenon, enelbin, xanthinal nicotinate;
- venotonics - troxevasin, escusane, cyclo-3-fort
- neuroprotectors - actovegin, tanakan, cerebrolysin, cytochrome C, nootropil, riboxin;
- angioprotectors - ascorutin, calcium dobesilate, troxerutin;
- hemodilution - fresh-frozen plasma, low-molecular dextrans (reopliglyukin, reomacrodex);
- decongestants - diuretics (furosemide, lasix), L-lysine escinate;
- non-steroidal anti-inflammatory drugs - diclofenac, tselebrex, nimesulide, ibuprofen;
- drugs that improve neuromuscular conduction - neyromidin;
- to reduce muscle tone - midokalm, baclofen;
- B group vitamins are neurorubin, milgamma.
Additionally used (depending on the cause of the stroke): immobilization of the affected vertebral segment, stretching, drug blockages, massage, exercise therapy, methods of physiotherapy.
Conservative treatment of hemorrhagic stroke consists in the application of:
- drugs that strengthen the vessel wall, to prevent the recurrence of hemorrhage - dicinone (sodium etamzilate), countercale, gordoks, aminocaproic acid;
- preparations for the prevention of vasospasm - nimotop, verapamil;
- neuroprotectors and angioprotectors.
If the conservative treatment is ineffective, and in cases of spinal cord injuries, tumor formations that squeeze the brain, surgical treatment is indicated in the neurosurgeon.
A special role in the treatment of spinal strokes is the prophylaxis of pressure sores, pneumonia and urogenital infections, which often complicate this disease with insufficient care for the patient.
To avoid decubitus, you need to monitor the cleanliness of the underwear, wipe the body with camphor alcohol, powder the folds of the skin with talcum, turn the patient every 1-1.5 hours. You can use special devices for the prevention of pressure sores - the rubber circle, the ring.
If it is impossible to urinate independently, urinary bladder catheterization is carried out, and urinary incontinence devices are used. Sexual organs should be kept clean for the prevention of an ascending infection.
To avoid the development of pneumonia, it is necessary to hold respiratory gymnastics every hour for 5 minutes (while bed rest is observed). In the future, with the expansion of the regime, dosed motor activity is necessary.
The consequences of a suffered spinal stroke can be very different. With a small size of the focus, timely medical therapy or surgical treatment is possible 100% recovery, but the patient must undergo clinical follow-up and preventive treatment courses. A less favorable outcome is also possible, when, despite treatment, the patient has motor, sensory and pelvic disorders. Such violations can lead to disability:
- paresis of limbs (one or several) - weakness in the muscles is retained, which makes it difficult for self-movement and self-service;
- sites of hypoesthesia or anesthesia - on the trunk or extremities is reduced or there is no sensitivity. This can be as painful, temperature, tactile sensitivity, and more complex types of sensitivity, such as a sense of localization, stereotype (recognition objects to the touch with closed eyes), a two-dimensional-spatial feeling (the ability to recognize with closed eyes the letters on the body, letters), etc. For some patients, this can be a cause of disability - a seamstress or musician can not perform professional skills in the absence of sensitivity in the hands;
- disturbances of urination and defecation - this problem is especially painful for patients, as it affects the intimate sphere of a person. There are very different in the degree and nature of the disorder: urinary incontinence, constant urine release by drop, periodic uncontrolled urination, the need to push to urinate, the incontinence of stool.
Recovery after a spinal stroke can be prolonged. It is most active in the first 6 months. First of all, such patients need psychosocial adaptation, since spinal stroke dramatically changes their habitual way of life. Recovery after a previous spinal stroke is a lengthy and time consuming process, sometimes it takes years to restore lost functions. However, qualitative rehabilitation measures after hospital treatment allow most patients to return to full-fledged life.
During the recovery period, the patient is shown repeated medication courses (at least once every six months).
An important role belongs to kinesiotherapy - physiotherapy. At a time when the patient himself can not move a limb, this is passive gymnastics. When arbitrary movements become possible, this is already a special set of static and dynamic character (preferably developed by a rehabilitator individually for a particular patient).
Many patients have to learn to move using additional means - walking sticks, walkers, special longos. In some cases, orthopedic shoes may be needed.
A very good effect in the recovery period is provided by massage. Repeated courses increase effectiveness. Along with the massage, it is possible to use acupuncture.
With muscle weakness, electrical stimulation is shown. Among other methods of physiotherapy, it should be noted magnetotherapy, sinusoidal modulated currents (with pareses), phonophoresis and electrophoresis, underwater shower-massage, hydrogen sulphide and carbon dioxide baths, paraffin and ozocerite applications.
Occupational therapy and vocational guidance are also part of the rehabilitation program.
Of course, the most complete set of restorative measures is realized at a sanatorium-and-spa treatment.