Ischemic stroke of the brain: treatment, prognosis
Annual indices of mortality of Russians argue that the strokes are the most significant part of it. In most cases, the outcome is irreversible disability. In the Russian Federation, the strokes are recognized as a major cause of profound disability.
A fifth of patients who received injury in the brain result of the disaster, are permanently bedridden. The structure of causes of disabling human brain incidents of strokes can be ischemic, in comparison with other types, the overwhelmingly predominate. For example, compared with hemorrhagic, ischemic brain stem stroke affects men five times more often.
How is an ischemic stroke?
Allocate the basic versions of the mechanism of occurrence of ischemic strokes:
- the embolic.
Thrombotic variant caused by primary thrombosis of cerebral vessels, in the lumen which has accumulated atheromatous layers. Embolic option due to blockage of vessel by embolus from a distant source. Most often the birthplace of emboli is the heart. They are formed as a result of parietal thrombotic events in heart attacks, after valve replacement, on the background of atrial fibrillation, infectious endocarditis, atrial myxomas. Sometimes the emboli are small particles, separated from ulcerated atheromatous plaques in the aortic arch or of the orifices of the major vascular trunks.
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The main types of strokes
According to the differences in the conditions of occurrence of ischemic strokes are divided into types:
- with the defeat of vessels of large diameter, caused by atherothrombosis or arterio-arterial embolism;
- cardioembolic origin;
- microvascular so-called lacunar strokes.
Depending on how long the neurological status of the patient keeps the symptoms of the defect, is isolated:
- transient ischemia attack or TIA in which neurological defects completely restored in days;
- small strokes, in which the recovery takes a week;
- completed strokes, characterized by the preservation of defects longer than a week.
What is the «ischemic cascade»
In the event of ischemia of any part of the brain, the cells are in the conditions of oxygen starvation, in them there are processes that violate the metabolism. From the very first minute of ischemia due to energy deficiency lightning pace begin to develop mechanisms of necrotic cell death of the suffering area of the brain called the «ischemic cascade».
Within five minutes already formed the nuclear area – the «core» of a heart attack. But located around areas of the brain, in which only lowered the blood supply, in General, maintain energy metabolism, they suffer functionally, but not structurally and retain their viability. The cell regeneration of these areas is the task of therapy for stroke patient.
As manifested ischemic strokes?
Clinical manifestations in stroke are very diverse. It can be various degrees of severity:
- paresis and paralysis, manifested by numbness or weakness of the limbs;
- speech disorders;
- unsteadiness of gait;
- bouts of nausea and vomiting.
For strokes of thrombotic origins characterized by progressive neurological defect. They develop sequentially or the episodes nerastas aggravating the overall neurological picture. For several days before stroke patients concerned about:
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- headaches accompanied by weakness, dizziness, blurred vision;
- periodically there is a sensation of numbness in the extremities;
- the intensity and duration of attacks increase until a few hours or days the patient feels that the limb refuses to act.
Usually ischemic stroke is the consciousness of the patient does not lose, he feels a stupor, “blurred in my head.» When emboli’s clinic is developing at lightning speed, appearing immediately in all its severity and accompanied by loss of consciousness. But lacunar stroke occurs, usually oligosymptomatic, with minimal neurologic defect. May experience only a few symptoms:
- easy dysarthria;
- paresis of gaze;
- awkwardness weakness in the wrist.
The strategy of therapeutic interventions in ischemic stroke
It is proved that ischemic stroke is half the infarct zone is formed over the first 90 min of cerebral catastrophe, the rest over the subsequent 360 min. So the initial 3 – 6 hours of the disease are the so-called «therapeutic window». This time, the most effective therapeutic effects.
That’s why when you stroke it is necessary to organize specialized assistance already in the first 2 – 3 hours of the disease. The complex of therapeutic measures should combine parallel conducting basic and pathogenetic therapy. The timeliness and reasonableness of the treatment depend on the capacity for work and prognosis of the patient.
Basic events in stroke
Basic therapy must prevent hypostatic pneumonia, contractures, bedsores, purulent ulcers of the cornea.
- From the first day of the disease turn patients in bed, perform passive movements in joints.
- They sanitize the airway, for patients with vomiting nasogastric probes are installed.
- Patients with dysphagia connect the parenteral nutrition.
- Is the aiming control of the functioning of the excretory organs.
All life-supporting activities are carried out on the background of controlled relative hypertension. The systolic pressure is maintained at 10 mm above the so-called «working», level keep diastolic below 110 mm Hg. article
- Infusion of funds regulated by water-salt metabolism.
- Under the control of osmolarity and pH-balance of blood and urine, electrolyte levels.
- Monitored biochemical parameters of blood.
- Eliminates the risk of brain edema and intracranial hypertension.
- If necessary connect the therapy comorbidities, introduced anti-arrhythmic or anti-infective drugs.
The main directions of pathogenetic therapy
Modern drug therapy for stroke is pathogenic, that is, corresponds to the understanding of the mechanisms of disease development. It combines two main areas:
- extremely speedy restoration of krovoobrascheniya tissues of the affected area of the brain called the otherwise early recanalization and reperfusion;
- neuroprotective therapy.
Recanalization and reperfusion
Restoration of patency of occluded vessels (i.e., recanalization) of the affected area of the brain and restoration its adequate krovoobrascheniya (i.e., reperfusion) can be either therapeutic or surgical method, that is, either thrombolysis or surgical removal of blood clots through its endovascular extraction or excision.
- Anticoagulants used in the thrombolysis, are assigned in the acute period in the absence of the threat of hemorrhagic complications and in the control of the coagulation capacity of blood.
- Antiplatelet agents designed to neutralize hemodynamic defects, that is, to provide reperfusion colonrectal zone, begin to use at 3 – 5th day of disease and then applied permanently.
- in/in the drip Cerebrolysin, Piracetam;
- sublingual Glycine;
- intranasal Semax.
- speech therapy;
- therapeutic exercises;
- psychological adaptation.
A highly efficient use of Pentoxifylline, Thrombohemorrhagic ACCA, Aspirin Cardio. Quite a positive effect on the hemodynamics of the brain Vinpocetine. Patients older than 55 years antiaggregatory effect provide β-blockers with Anaprilin, Obsidiana, Inderal. Older patients it is expedient to ensure reperfusion with a angioprotectors Prodektina, Anginine, Parmidin, with antiplatelet effects.
Neuroprotective therapy targets the main stages of the “ischemic cascade”. Stroke patients in the first hours and days of the disease are introduced:
Proven efficacy and safety in ischemic stroke Remacemide similar action has proven for decades magnesium Sulfate. High antioxidant efficiency exhibit domestic products Mexidol and Emoxipin. They are safe and well tolerated.
The implementation of reparative therapy, aimed at maintaining a viable area surrounding the infarct, is a secondary neuroprotective agents, nootropics, choline derivatives, such as Gliatilin. They enhance the regenerative and reparative process, thus contribute to the restoration of the reduced functions of neurons. For example, the domestic drug Aplugin containing carnitine chloride, even in the acute period, providing «Wake-up» effect on seriously ill patients, accelerates regression of focal symptoms and mental disorders positively affects the course and consequences of ischemic stroke.
Rehabilitation strategy in ischemic stroke
In the recovery process are equally important positions are:
The ultimate goals of rehabilitation interventions in stroke are complete regression of neurological impairment and rehabilitation of the person.