Ischemic stroke: symptoms and treatment

Ischemic stroke is an acute disorder of cerebral circulation in a certain arterial basin, which leads to a focus of necrosis of the brain tissue and is accompanied by a persistent neurologic deficit, which persists more than 24 hours.

Ischemic stroke is the most common form of cerebral circulatory disorders and is about 80%. In our country the death rate from this disease remains one of the highest in the world, more than 400 thousand are registered annually. strokes, which if not terminate lethal, so lead to persistent disability.

Risk Factors for Stroke

Forewarned - so armed, so if you know what causes this ailment, you can prevent this disease. The risk factors for stroke include:

• atherosclerosis;
• hypertensive disease (untreated hypertension with figures of blood pressure more than 200/100 mm Hg. Art. increases the risk of getting sick 10 times);
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• IHD (especially the presence of such rhythm disturbances as atrial fibrillation);
• diabetes;
• tobacco smoking;
• obesity, hyperlipidemia;
• TIA in the anamnesis;
• male sex (in men, strokes occur more often);
• elderly age.

I would like to note that at the moment the stroke is not considered as a separate nosological unit, but for him it is possible to single out a single etiologic factor - atherosclerosis.

Symptoms of ischemic stroke

Depending on the degree of disturbance of cerebral blood flow, the following variants of stroke manifestation are possible:

• acute onset: the rapid appearance of neurological symptoms and deficits, the patient can clearly indicate the time of onset of the disease. Such a course is characteristic of the embolic variant of stroke (the presence of atrial fibrillation in the patient);
• an undulating beginning: the symptoms of the lesion are "flickering", gradually growing in time;
• tumor-like beginning: ischemia builds up for a long time, hitting the main vessels of the brain, which eventually leads to an unfolded stroke with a large focus of damage to the brain tissue.

The first signs of a stroke, to which the patient should pay attention:

• violation or difficulty of speech;
• severe headache, which does not go away after taking NSAIDs;
• weakness and numbness of the limbs, half of the body;
• marked dizziness, which is accompanied by nausea and vomiting;
• violation of orientation in space, time and self;
• sudden blindness to one eye or loss of visual fields.

Dangerous symptoms must be known to everyone, since untimely seeking medical help significantly worsens the prognosis of the course of the disease. The earlier the patient resorts to specialized medical care, the more likely will be for a speedy recovery and recovery of lost functions, as the time count goes by the minute.

Classification of stroke

The most common is the classification of TOAST, in which the following options are distinguished:

• cardioembolic: emboli are thrombi that form in the heart cavity with atrial fibrillation, mitral cardiac disease, recent myocardial infarction;
• atherothrombotic: in the lumen of large arteries, an atherosclerotic plaque builds up, which ulcerates and forms clots on it. If plaque rupture occurs, then arterio-arterial embolism develops;
• hemodynamic: stroke develops against a background of gross stenosis 70% of both intracranial and extracranial vessels in combination with a sharp fall in blood pressure;
• hemorheological: thrombosis in the vessels of the brain arises from hematological diseases (hypercoagulation of the blood-erythremia, thrombocythemia, etc.);
• lacunar infarction: thrombosis of the brain arterioles in the subcortical nuclei. The hearth is 15 mm on the average, but is characterized by its clinic, therefore it is isolated in a separate group.

Depending on what affects the vascular pool, the following strokes are indicated:

• Carotid pool:

1. internal carotid artery;
2. anterior cerebral artery;
3. middle cerebral artery.

• Vertebrobasilar swimming pool:

1. vertebral artery;
2. basilar artery;
3. cerebellar infarction;
4. posterior cerebral artery;
5. a thalamus infarction.

The clinic of ischemic stroke is characterized by a sudden onset with the appearance of a persistent neurological deficit, which persists for more than 24 hours. I would like to note that hemorrhagic stroke is dominated by general cerebral symptoms. For ischemic stroke, focal lesion comes to the fore, which manifests itself in the form of paralysis of the arm and leg on one side, faces, speech disorders and swallowing act, blindness or loss of visual fields, disorders sensitivity. The lesion focus corresponds to a certain vascular basin, in which a brain catastrophe occurred. General cerebral symptoms are manifested in the form of oppression of consciousness, headache, dizziness and is more pronounced with extensive hemispheric infarcts, cerebral and cerebellar infarctions.

In the development of stroke, the following periods are distinguished:

• acute- this is the first 3 days. If symptoms regress after 24 hours, then a transient ischemic attack (TIA) is diagnosed. In the acute period, the leading value is given to the first three hours after the manifestation of a brain accident - the so-called therapeutic window (it is in this period of time that it is possible to actively and crucially affect the course of a stroke by performing a thrombolytic therapy);
• acute- up to 28 days. If the neurologic deficit regresses to 21 days, then this condition is regarded as a minor stroke;
• early recovery- up to six months;
• late recovery- Up to 2 years;
• period of residual manifestations- More than 2 years.

Principles of treatment of ischemic stroke

The main task of pathogenetic therapy for stroke is reperfusion - restoration of adequate blood flow. The patient has a chance - in the first 3 hours after the manifestation of a stroke, an intravenous thrombolytic therapy with a recombinant tissue plasminogen activator (actilize or alteplase). Treatment is carried out in the block of intensive therapy of the stroke department, indications and contraindications determines physician, since this therapy, together with tremendous positive results, can cause serious complications. To prevent persistent disability by successful thrombolysis is possible in 50% of cases.

It is also possible to perform selective intra-arterial thrombolysis in a specialized department interventional endovascular neuroradiology, which is conducted 6 hours after the onset stroke. Intraarterially selectively, urokinase is administered. The positive result increases significantly with the simultaneous removal of the thrombus loop and subsequent stenting. With this method of treatment, the efficiency reaches 60%.

Antiaggregant therapy.All patients with ischemic stroke from the first day of the disease are prescribed antiplatelet drugs - aspirin cardio, tromboAss. The exception for the first day is the patients after systemic intravenous thrombolysis. These drugs are used for life in order to prevent repeated ONMC.

Anticoagulant therapy.Anticoagulants in ischemic stroke are appointed very carefully and according to strict indications: most often it is cardioembolic strokes, patients with mitral stenosis, with thrombosis of cerebral veins and sinuses, thrombophilia expressed carotid stenoses, etc. These drugs are not categorically prescribed after thrombolysis. Appointed as an anticoagulant direct action, and low molecular weight heparins.

Infusion therapy.Infusion therapy is performed in the normovolemia mode with solutions of crystalloids to maintain hematocrit at a level of 33-35%, taking into account the concomitant pathology of the patient. It is necessary to maintain a mean blood pressure of 20% above the baseline in order to avoid secondary cerebral ischemia.

Vasoactive drugs.Vasoactive drugs (vinpocetine, sermion, trental, instinon, etc.) in the acute stage of ischemic stroke are not prescribed, since they can lead to the syndrome of steal and secondary ischemia the brain.

Neuroprotective agents.Attitude to neuroprotectors and antioxidants (glycine, semax, cerebrolysin, gliatilin, mexidol, cortexin, etc.) is ambiguous. Based on the name of the group, they have a protective effect on the affected brain tissue. But, unfortunately, in clinical trials they have not proven effective, and most protocols do not recommend their use. A positive opinion remained about magnesium sulfate, as it blocks NMDA receptors and still has a protective effect on the brain.

In addition to pathogenetic specific therapy for stroke, there is a basic therapy that is used for all types of strokes. It must be observed scrupulously, since it is the basic therapy that significantly influences the outcomes of the disease. It includes:

• adequate function of external respiration and oxygenation (control of saturation, if necessary oxygen therapy, with violation of airway patency - intubation with ventilation);
• monitoring of blood pressure, ES, S (blood pressure should be maintained at 20% above the baseline, while not allowing both its increase and decrease, because this can lead to secondary cerebral ischemia);
• normal blood glucose level;
• control of water and electrolyte balance;
• maintenance of normothermia;
• struggle with brain edema and convulsive syndrome;
• adequate enteral and if necessary parenteral nutrition (gastric sounding in the presence of bulbar syndrome);
• prevention and treatment of complications (pneumonia, pressure ulcers, urinary tract infections, lower extremity thromboembolism and PE, stress ulcers).

The emphasis on basic therapy is of great importance, since patients die not from a stroke, but from its complications.

In conclusion, I would like to note that at present, patients with stroke seek specialized medical care very late (an average of 10-12 hours), when thrombolysis can no longer be carried out, losing valuable time. Despite the significant advances in medicine, the treatment of an already developed stroke is a very difficult task and not always effective and grateful. The greatest importance is prevention, since preventing the development of a brain accident, knowing the risk factors, is much easier than treating its consequences. And the price of the issue is high enough: a normal life or a wheelchair, because, according to statistics, if the patient survives, then in 50% of cases it remains disabled.

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