Cerebral atherosclerosis is the process of formation of atherosclerotic plaques inside the cerebral vessels, resulting in disorders of the cerebral blood supply. It may have a subclinical course or manifest itself as dyscirculatory encephalopathy, TIA, stroke. The diagnosis uses REG, ultrasound, duplex scanning or MRI of cerebral vessels, as well as electroencephalography, CT and brain MRI. Combined therapy with the appointment of hypolipidemic, antiplatelet, nootropic, neurometabolic, vascular pharmaceuticals. If there are indications, surgical treatment is performed.
ICD 10
I67.2 Cerebral atherosclerosis
General information
Cerebral atherosclerosis accounts for about a fifth of all neurological pathology and about half of cardiovascular diseases. Atherosclerotic processes in cerebral vessels can start as early as 20-30 years of age, however, due to the long subclinical course, the manifestation of the disease usually occurs after 50 years. Clinical manifestations of cerebral atherosclerosis are associated with gradually developing cerebral circulatory insufficiency and ischemia of brain tissues as a result of vascular damage. Chronic cerebral ischemia, along with coronary heart disease, is the most severe consequence of atherosclerosis. It can cause complications such as stroke and dementia. Due to the high prevalence and high frequency of complications, atherosclerosis of cerebral vessels is one of the most priority problems of modern neurology.
Causes
A number of factors contributing to the development of cerebral atherosclerosis are known. These include, first of all, age. With age, atherosclerosis of blood vessels is observed in all to one degree or another. Earlier development of atherosclerotic changes and faster progression of cerebral atherosclerosis is noted with an unbalanced diet (excessive consumption of fats and carbohydrates, insufficient amount of plant foods, overeating, the presence of fried and spicy dishes in the diet, etc. P.), metabolic disorders (obesity, diabetes mellitus, hormonal failures), physical inactivity, smoking, frequent intake of large doses of alcohol.
Favorable conditions for the occurrence and progression of atherosclerosis are formed against the background of arterial hypertension. Often atherosclerosis and hypertension develop together, mutually aggravating each other. Chronic infections and intoxications that have an adverse effect on the vascular wall are also factors contributing to the occurrence of cerebral atherosclerosis. Of no small importance is the psycho-emotional state that determines a person’s perception of various life events. The lack of a calm, friendly attitude leads to the fact that many situations become stressful for a person. Stress negatively affects the tone of the walls of cerebral vessels and causes a pressure drop. The numerous repetition of such vascular changes is a favorable basis for the development of cerebral atherosclerosis.
Not all questions of the etiology of atherosclerosis are completely clear. The existence of a large number of predisposing factors suggests the polyetiology of this process. However, the question remains open as to why in some patients there is damage mainly to the heart vessels, and in others — to the cerebral ones. It is also necessary to take into account a certain role of hereditary mechanisms, since family cases of such complications of cerebral atherosclerosis as stroke are widely known.
Pathogenesis
The main factor in the mechanism of atherosclerosis development is considered to be lipid dysmetabolism. As a result of a malfunction in metabolism, low-density lipoprotein cholesterol (LDL) is deposited on the inner surface of the walls of cerebral vessels. Arteries of large and medium caliber are mainly involved in the process. The formation of the so-called atherosclerotic plaque occurs in stages – from a fat spot to atherocalcinosis. The resulting atherosclerotic plaque, increasing in size, gradually increasingly blocks the lumen of the affected vessel and can serve as a source of thromboembolism.
In the first case, due to the progressive decrease in the lumen of the vessel, there is a decrease in blood supply to a certain area of the brain. Hypoxia and lack of nutrients occur in the cerebral tissues of this zone — chronic ischemia develops, which eventually leads to degeneration and death of individual neurons. Clinically, this process is manifested by symptoms of dyscirculatory encephalopathy (DEP). The severity of the latter depends on the prevalence of atherosclerosis, the caliber of the affected vessel, the size of the atherosclerotic plaque, the degree of development of alternative (collateral) blood supply to the ischemic area of the brain.
In the second case, part of the atherosclerotic plaque breaks off from it and in the form of an embolus with blood flow is transferred to a smaller arterial vessel, causing its sudden and complete occlusion (thrombosis). Depending on the size of the blood supply zone of the occluded artery and the degree of development of vascular collaterals, a transient ischemic attack (TIA) or ischemic stroke occurs. More rarely, cerebral atherosclerosis is the cause of hemorrhagic stroke. Rupture of the vascular wall occurs due to a violation of its elasticity at the site of formation of atherosclerotic deposits and is often caused by high arterial hypertension.
Symptoms
Clinically, cerebral atherosclerosis begins to manifest itself when atherosclerotic plaques located inside the vessels block the cerebral blood flow so much that ischemia occurs and discirculatory encephalopathy develops. In accordance with the severity of cerebral circulatory disorders, there are 3 stages of cerebral atherosclerosis.
- Initial stage. Symptoms are transient in nature, often occur with psychoemotional and physical overload and disappear in rest conditions. There is an asthenic syndrome: weakness, unusual fatigue, increased irritability, lethargy, difficulty concentrating. There may be periodic sleep disorders in the form of insomnia and / or daytime drowsiness, sometimes dizziness. There is a slight decrease in the pace of thinking, the ability to memorize and retain new information in memory. In many patients during this period, a headache complaint comes to the fore, combined with noise in the head, ears or one ear.
- Progressive cerebral atherosclerosis. Mnestic disorders and psychoemotional changes in character are aggravated. The general mood background decreases, depression may develop. The patient becomes suspicious and anxious. Memory disorders become clearly pronounced — the patient and his relatives say that he cannot remember the events of the current day, confuses them. The noise in the head becomes permanent. There is vestibular ataxia, indistinctness of speech. Tremor of the fingers or head is possible, there is often a decrease in vision and some hearing loss. The ability to perform productive professional activities is gradually being lost.
- Dementia. Intellectual decline is progressing, memory lapses, speech disorders, apathy, sloppiness, complete disappearance of interests are observed. The patient loses the ability to navigate in the environment and in time, loses self-service skills, requires supervision.
Diagnostics
In the neurological status of patients with cerebral atherosclerosis, depending on the stage of the disease, upward gaze paresis, horizontal nystagmus, some anisoreflexia, symmetrical increase or lethargy of reflexes, instability in the Romberg pose, tremor of outstretched fingers, violation of coordination tests may be detected. After a stroke, there may be paresis and other neurological deficits. Ophthalmoscopy performed by an ophthalmologist can reveal atherosclerotic changes in retinal vessels. With hearing loss, an otolaryngologist’s consultation with audiometry is indicated.
Vascular studies allow for more accurate diagnosis of cerebral atherosclerosis. The most accessible of them is REG. Ultrasound of the vessels of the head, duplex scanning and MRI of the vessels of the brain are more informative. It is important to conduct vascular studies in dynamics, to assess the degree of occlusion of the carotid arteries and the main intracranial arteries. EEG is used to analyze the functional state of the brain, CT and brain MRI are used to visualize cerebral tissues (especially during the diagnosis of strokes).
Treatment
It is impossible to cure cerebral atherosclerosis, but by timely, regular and complex therapy, its progression can be slowed down. First of all, it is necessary to eliminate the factors that aggravate the development of the atherosclerotic process. It is necessary to follow a plant-based diet with the exception of nutrients with a high cholesterol content (meat, eggs, margarine, canned fish, sausage, fast food), introduce daily hiking, reduce psycho-emotional stress, eliminate smoking and alcohol intake, optimize body weight. Hypertensive patients need careful selection of antihypertensive treatment. Correction of the blood lipid spectrum is important, which is prescribed according to the results of a study of the content of cholesterol and lipids in the blood. Hypolipidemic pharmaceuticals are prescribed: simvastatin, atromidine, fluvastatin, gemfibrozil, etc.
Pathogenetic treatment of cerebral atherosclerosis aims to improve the metabolism and blood supply of neurons, increase their resistance to ischemic conditions, prevent thrombosis, improve mnestic functions. As an antiplatelet therapy, long-term administration of ticlide or small doses of acetylsalicylic acid is prescribed. Vascular therapy is performed with pentoxifylline and vinpocetine, nifedipine. Neurometabolic treatment includes the appointment of B vitamins, glycine, gingko biloba preparations. Cognitive abilities are improved by taking nootropics: piracetam, picamilon, nicergoline, etc.
Repeated TIA, a minor stroke, occlusion of the carotid arteries with a decrease in its lumen by more than 70% are indications for surgical treatment of cerebral atherosclerosis. There are 2 types of operations: endarterectomy (removal of an atherosclerotic plaque together with a portion of the intima of the vessel) and the creation of a vascular shunt bypassing the area of the artery obstructed by an atherosclerotic plaque. According to the indications, neurosurgeons perform carotid endarterectomy, the formation of an extra-intracranial anastomosis, brachiocephalic stem prosthetics and other operations.
Forecast
The prognosis of cerebral atherosclerosis is very variable. Much depends on the age of the patient, the timeliness of the treatment measures initiated, the ability to completely eliminate the existing risk factors. The most severe complications of cerebral atherosclerosis are stroke and dementia, which result in severe disability of the patient and possible death.
Prevention
The best prevention of atherosclerosis of any localization is a healthy lifestyle, which implies reasonable physical activity, rational nutrition, staying in the fresh air, a calm rhythm of life with an adequate alternation of work and rest. The prevention of the development of the atherosclerotic process is the exclusion from one’s life of all factors contributing to its progression, including unfriendly reactions (anger, anger, resentment, irritation, etc.) that provoke tonic changes in cerebral vessels. Timely adjustment of one’s lifestyle, adequate treatment, and, if necessary, improvement of cerebral blood flow surgically — all these measures can be attributed to measures of secondary prevention of cerebral atherosclerosis, which allows avoiding its complications such as stroke and dementia.
