Cerebrospinal circulation disorders are acute and chronic circulatory disorders caused by pathology or extravasal compression of blood vessels supplying the spinal cord. Clinical manifestations of cerebrospinal circulation disorders can be para- and tetraplegia, paresis, violation of various types of sensitivity, urination and defecation disorders. In the diagnosis of vascular disorders, CT and MRI of the spine, angiography, electrophysiological studies are used. To normalize spinal circulation, drug therapy is carried out, sometimes surgical revascularization of the spinal cord. Rehabilitation is indicated to restore impaired functions.
General information
Vascular lesions of the spinal cord, accompanied by a violation of spinal circulation, may have different etiologies. Various pathology of the vessels of the spinal cord or their compression from the outside leads to disruption of normal blood flow and damage to the part of the spinal cord supplied by them. In most cases, cerebrospinal circulation disorders occur in the form of myeloishemia (ischemic spinal stroke). Hemorrhages in the spinal cord (hematomyelia) are less common.
In some cases, disorders of the cerebrospinal circulation may be reversible, in others – lead to irreversible neurological disorders and permanent disability. In neurology, they are usually considered as critical urgent conditions that require immediate response.
Causes
Among the causes of ischemic cerebrospinal circulation disorders , there are 3 groups of factors:
1. Pathological changes in blood vessels supplying the spinal cord are the cause of 20% of myeloishemia.
- congenital: vascular hypoplasia, aneurysms, aortic coarctation;
- acquired: atherosclerosis, thrombosis, embolism, varicose veins, arteritis, phlebitis, circulatory insufficiency in heart failure
2. Compression of blood vessels supplying the spinal cord from the outside is the most common cause of ischemic disorders of spinal circulation, it occurs in 75% of cases of myeloishemia. Thus, tumors or enlarged lymph nodes of the thoracic and abdominal cavities can compress the aorta and its branches; intervertebral hernia, tumor, inflammatory infiltrate, fragments of a vertebra with its fracture can lead to compression of the arteries and root veins of the spinal cord.
3. The influence of iatrogenic factors is an etiological factor of 5% of myeloishemia. These are complications of surgical interventions on the spine or aorta, diagnostic operations (lumbar puncture), spinal anesthesia, local administration of drugs into the spine, manual therapy, etc.
Cerebrospinal circulation disorders in the form of spinal hemorrhage are usually caused by rupture of a spinal vessel aneurysm or damage to a vessel during spinal injury. Diseases such as infectious vasculitis, hemorrhagic diathesis and others can lead to the development of hematomyelia.
Classification
Disorders of cerebrospinal circulation are divided into:
- acute — sudden: ischemic and hemorrhagic spinal stroke;
- transient — sudden disorders of the cerebrospinal circulation, in which all symptoms disappear within the first day from the moment of their appearance, they include: “falling drop” syndrome, Unterharnscheidt syndrome, myelogenous intermittent claudication, caudogenic intermittent claudication;
- chronic — long-term and slowly progressing: chronic myeloishemia.
Symptoms
Ischemic spinal stroke. Acute ischemic disorders of the cerebrospinal circulation often develop within a few minutes or 1-2 hours, but in some cases, symptoms may increase gradually over several days. Attacks of transient ischemia may be harbingers of the development of ischemic spinal stroke. If the stroke develops rapidly, the patient may experience an increase in body temperature and chills. Otherwise, the clinical picture of a stroke depends on the localization and extent of the spread of ischemia across the spinal cord.
In ischemic stroke at the level of C1-C4 segments of the spinal cord (upper neck), there is a lack of movement in all limbs (tetraplegia), increased muscle tone, violation of all types of sensitivity (pain, tactile, temperature) below the level of the lesion, urinary retention. It is possible to develop paralysis of the respiratory muscles, and with the rapid development of ischemia, spinal shock.
Ischemic lesion of the cervical thickening (C5-C6) is characterized by muscle weakness of all limbs (tetraparesis or tetraplegia) with a decrease in muscle tone in the arms and an increase in it in the legs, a violation of all types of sensitivity below the level of the lesion, delayed urination. Gorner’s syndrome is characterized by enophthalmos, narrowing of the pupil and eye slit.
Acute ischemic disorders of spinal circulation in the thoracic region are characterized by weakness in the legs with increased muscle tone (lower spastic paraplegia), impaired sensitivity, urinary retention. At the same time, abdominal reflexes are not detected.
With ischemia at the lumbar level, peripheral (sluggish) paralysis of the upper legs develops, characterized by a decrease in muscle tone. At the same time, the muscular strength in the feet is preserved, the Achilles reflexes are increased, and the knee ones are not determined. All types of sensitivity from the inguinal fold and below are violated. There is a delay in urination. With ischemic violation of the cerebrospinal circulation in the area of the cerebral cone (lower lumbar and coccygeal segments), there is a violation of sensitivity in the perineum, incontinence of urine and feces. In case of violation of cerebrospinal circulation at any level of the spinal cord, trophic changes of innervated tissues occur and bedsores are formed.
Hemorrhagic spinal stroke develops acutely with spinal injury or after significant physical exertion (for example, lifting weights). Clinical symptoms depend on the level of location of the hematoma formed as a result of hemorrhage. Muscle weakness appears, sensitivity disorders and changes in muscle tone develop, as in ischemic stroke, corresponding to the level of lesion. There may be a violation of urination and defecation. With hemorrhage in the upper neck segments of the spinal cord, paralysis of the diaphragm muscles is possible, leading to respiratory failure.
The “falling drop” syndrome is a transient violation of the cerebrospinal circulation that occurs when the head is thrown back or its sharp turn. In this case, the patient suddenly falls due to a sharp weakness in the limbs, loss of consciousness does not occur. Pain in the neck and back of the head is often noted. After a few minutes, the attack passes and the strength in the muscles of the limbs is restored. But with the next sharp turn of the head, the attack may repeat. Such conditions occur due to ischemia of the cervical segments of the spinal cord and are observed in severe degenerative-dystrophic changes of the spine in the cervical region, pronounced atherosclerotic lesions of the vertebral arteries.
Unterharnscheidt syndrome has a clinical picture similar to the “falling drop” syndrome, but it is characterized by loss of consciousness. An attack of sudden weakness in the extremities occurs with sharp turns of the head and is accompanied by a blackout for 2-3 minutes. After an attack, consciousness is restored somewhat earlier than muscle strength, and the patient can not move his arm or leg when he wakes up. After 3 to 5 minutes, the movements are restored, there is a feeling of weakness in the whole body. Unterharnscheidt syndrome occurs when ischemic disorders of spinal circulation affect not only the cervical segments of the spinal cord, but also the brain stem adjacent to them from above.
Myelogenous intermittent lameness is a paroxysmal weakness in the lower extremities, accompanied by numbness, and in some cases — a sudden and strong urge to urinate or defecate. Seizures occur when exercising or walking long distances. After a 10-minute rest, all symptoms go away and the patient moves on. Such patients note frequent twisting of the legs when walking. This variant of cerebrospinal circulation disorder often develops against the background of concomitant lower back pain (lumbalgia) or pain along the sciatic nerve (lumboishialgia). In this case, it is caused by osteochondrosis and compression of one of the root-spinal arteries of the lumbar disc herniation. Less frequently, intermittent claudication occurs with atherosclerotic lesions of the branches of the abdominal aorta or spinal vasculitis.
Caudogenic intermittent lameness is manifested by attacks of paresthesia appearing when walking in the form of numbness, tingling, crawling goosebumps. Paresthesia begins in the distal parts of the legs, rises higher, captures the inguinal region and genitals. If the patient tries to continue walking, he notes a sharp weakness in the legs. After a short rest, all these symptoms go away. This type of cerebrospinal circulation disorder is characteristic of narrowing of the spinal canal at the lumbar level. In some cases, there is a combined myelogenous and caudogenic lameness, which is characterized by both weakness in the legs and pronounced paresthesia.
Chronic insufficiency of spinal circulation, as a rule, begins with the occurrence of transient disorders of spinal circulation. Persistent and often progressive disorders of the motor sphere and sensitivity gradually develop. Depending on the level of the lesion, they may manifest as muscle weakness in the arms and legs (tetraparesis) or only in the legs (lower paraparesis), decreased or loss of sensitivity, changes in muscle tone, impaired urination and defecation.
Neurological complications of cerebrospinal circulation disorders include edema of the spinal cord, somatic ones include bedsores, secondary infectious diseases of the urinary tract, sepsis.
Diagnostics
Magnetic resonance imaging (MRI of the spine) is used to make an accurate diagnosis, differentiate cerebrospinal circulation disorders from tumor and inflammatory processes, determine the ischemic or hemorrhagic nature of spinal stroke, and if it is impossible to carry it out, computed tomography (CT of the spine) is used.
Spinal angiography is performed to diagnose pathological changes in blood vessels and to resolve the issue of surgical intervention. Electrophysiological research methods (electroneurography, electromyography, evoked potentials, transcranial magnetic stimulation) are prescribed to determine the degree and level of damage to conductive nerve fibers and the state of neuromuscular transmission.
Treatment
A patient with acute cerebrospinal circulation disorder should be hospitalized in the neurology department as soon as possible. During transportation, the patient lies on his back on a special shield. Drug therapy of ischemic spinal stroke is similar to the treatment of ischemic stroke of the brain. Drugs that dilate cerebral vessels (vinpocetine, nicergoline, cinnarizine) are used; vasodilating drugs that improve collateral circulation (bendazole, euphyllin, papaverine, nicotinic acid, drotaverine); drugs that stimulate the cardiovascular system (niketamide, scopolamine) and blood thinning drugs (pentoxifylline, dipyridamole, dextrans). Anticoagulants (heparin, nadroparin, acenocumarol, fenindione, etc.) are prescribed under the control of coagulation.
Drug therapy of hemorrhagic spinal stroke corresponds to therapeutic measures for hemorrhagic stroke of the brain. These are drugs that promote the formation of a blood clot and stop bleeding, aimed at strengthening the vessel wall and reducing its permeability.
Regardless of the type of stroke, the patient needs bed rest, regular emptying of the bladder, prevention of bedsores. To prevent brain edema, dehydration therapy (mannitol, furosemide) is performed. Drug therapy aimed at restoring lost functions is usually started on the second or third day. It includes neostigmine, gallants. A week later, neuroprotectors (a drug from the pig’s brain), nootropics (piracetam, ginko biloba extract), antihypoxants (hopanthenic acid, phenibut, meldonium), antioxidants (carnitine, vitamin E), B vitamins, etc. are prescribed. Along with medical treatment, physical therapy, physiotherapy and massage of the affected limbs are used.
Surgical treatment is performed by neurosurgeons. Spinal cord revascularization surgery is indicated when conservative therapy is ineffective. Spinal surgery is also necessary in cases where a violation of cerebrospinal circulation is caused by compression of the artery by a tumor, intervertebral hernia, a focus of inflammation, etc. Intervention is necessary when a vessel aneurysm is detected, since it allows to prevent its rupture and hemorrhage in the spinal cord.
Prognosis and prevention
The prognosis of cerebrospinal circulation disorders depends on its type, localization and extent of damage to the substance of the spinal cord. Early cessation of the damaging effects of the etiological factor and the beginning of treatment improve the prognosis. However, even in the case of a favorable outcome, persistent disorders of the motor and sensory spheres often persist. Bedsores and infectious complications can lead to the development of sepsis and death.
Prevention of cerebrospinal circulation disorders involves early detection of factors leading to their development (for example, aneurysms).