Ischemic spinal stroke is an acute necrosis of a part of the spinal cord tissue due to the cessation of its blood supply. It occurs due to blockage of the vessel by a thrombus, atherosclerotic plaque or compression of the artery from the outside. It is characterized by the development of paresis and paralysis of the extremities, disorder of the functions of the bladder and rectum. The diagnosis is established on the basis of clinical manifestations and confirmed by CT or MRI of the spinal cord. Conservative treatment is aimed at improving the blood supply to the area in the stroke zone, as well as at eliminating the causes that caused the blood flow disorder. In case of inefficiency, surgical methods are used.
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Ischemic spinal stroke is an acutely developed circulatory disorder in the spinal cord, which is based on the cessation of blood flow through the vessels feeding it. It is characterized by persistent neurological symptoms. In his practice, a neurologist encounters spinal strokes quite rarely, since they account for only about 1% of the total number of acute circulatory disorders in the central nervous system.
Ischemic spinal stroke can affect patients of various age categories; it is not uncommon for the pathological process to occur in young people aged 30-35 years. Men and women get sick with approximately the same frequency.
All causes of ischemic spinal stroke can be divided into 3 categories: damage to the heart and blood vessels – occurs in 20% of cases; compression of the vessel from the outside – is observed in 75% of patients; complication of medical manipulations – in 5% of patients.
Damage to the heart and blood vessels is represented by congenital anomalies of the structure of the cardiovascular system and acquired vascular lesions. Congenital disorder may be associated with underdevelopment of spinal vessels, aneurysms, anomalies of the structure of the aorta, varicose veins. Acquired lesions – atherosclerosis of the vessel walls; blockage of the artery lumen by a thrombus, embolus; low pressure in the blood vessels feeding the spinal cord due to severe heart failure, myocardial infarction.
Compression from the outside can be carried out due to compression of the aorta and the blood vessels departing from it by any formation in the thoracic or abdominal cavity. This may be a pregnant uterus, enlarged clusters of lymph nodes into which the tumor has metastasized, or affected by lymphogranulomatosis. Compression of the radicular-cerebral arteries occurs with a vertebral hernia, spinal cord tumors, injuries with vertebral fractures.
Ischemic spinal stroke can develop as a consequence of a violation of the technique of performing operations on the spine or surrounding tissues, when arteries are squeezed with a surgical clamp for a long time to prevent bleeding. Also, the cause of acute circulatory disorders may be spinal anesthesia, blockade of spinal nerve roots in sciatica.
Clinical manifestations of ischemic spinal stroke in their development go through 4 stages: this is the stage of precursors; the development of stroke; reverse development; the stage of residual phenomena.
The Harbinger stage
This stage can be either very short – a few minutes, or last for a long time – several months. A short stage is typical for sudden blockage of a vessel by a thrombus or embolus, as well as for compression of an artery in case of spinal injury. A long period of harbingers is observed if the cessation of blood circulation occurs gradually, for example, with the growth of a tumor or an increase in atherosclerotic plaque.
The precursors of ischemic spinal stroke include: intermittent lameness; pain along the spine; pain or discomfort (crawling goosebumps, numbness) along the branching of the spinal roots. Intermittent lameness is the name in neurology for a condition characterized by the appearance of weakness and numbness in the legs during prolonged standing or prolonged walking. It is associated with the occurrence of oxygen starvation in the area of the spinal cord responsible for the movement of the lower extremities, due to insufficient blood flow through the vessels.
The rate of development of ischemic spinal stroke depends on the cause that caused the cessation of blood supply to the spinal cord. If an embolus or a detached blood clot is to blame for this, but clinical signs develop within a few minutes. In other cases, there may be an increase in symptoms for several hours.
The picture of the disease depends on which vessel stopped the flow of blood to the spinal cord. So, for example, when the anterior spinal artery is blocked, paralysis of the extremities develops, a violation of the function of the bladder and rectum, skin sensitivity disappears in symmetrical areas of the arms and legs. When a stroke focus is found in the cervical spinal cord, sluggish (with reduced muscle tone) paralysis in the arms and spastic (with increased muscle tone) paralysis in the legs develops. If the thoracic parts of the spinal cord are affected, spastic paresis of both legs develops, and when the focus is localized in the lumbosacral segments, flaccid paresis of the lower extremities, stool and urine retention.
The reverse development of symptoms begins approximately 1 month after the onset of a spinal cord stroke. It is associated with the partial restoration of blood supply in the damaged area due to blood flow through the arteries from other large blood vessels, as well as with the restoration of the functions of neurons that managed to survive in the focus of a stroke. The reverse development is characterized by a gradual decrease in the level of sensitivity disorder, the return of a certain part of voluntary movements in the limbs and normalization of the pelvic organs.
The rate of reverse development and the degree of recovery of lost functions directly depends on the location of the ischemic stroke focus in the spinal cord and its size.
The stage of residual phenomena
The patient enters this stage approximately 2 years after the onset of the disease. It is characterized by the presence of persistent neurological disorders that do not have pronounced dynamics.
It is quite difficult to diagnose ischemic spinal stroke, since it resembles diseases such as polio, syringomyelia, spinal form of multiple sclerosis, cerebellar lesion. A detailed study of the precursors and the rate of development of clinical manifestations is very important. Taken together, they suggest the cause of the development of cerebrospinal circulation disorders.
Knowing which segment of the spinal cord is responsible for voluntary movements and sensitivity in certain areas of the body helps to establish the intended localization of the stroke focus. Instrumental methods allow to confirm the diagnosis: angiography; CT and MRI of the spinal cord; spondylography, myelography; electrophysiological studies.
Angiography makes it possible to see which lumen of a blood vessel has narrowed or clogged. Computer and magnetic resonance imaging allow you to accurately determine at what level of the spinal cord is the focus of a stroke. Spondylography and myelography are indispensable in case of suspected compression of a blood vessel from the outside by a spinal cord tumor, intervertebral hernia, fragments of vertebrae after injury. Electrophysiological studies (EMG and ENG) are necessary to clarify the violation of muscle innervation.
In the treatment of ischemic stroke, the following goals are set: improving the blood supply to the spinal cord in the stroke area; eliminating factors that caused blood flow disorders; restoring lost spinal functions. Improved blood supply is provided by increasing blood flow through neighboring arteries. To do this, vasodilators, blood flow-improving agents (antiplatelet agents), venotonizing and decongestant medications are prescribed. Medications that help to increase the resistance of spinal cord tissue to oxygen starvation are prescribed without fail.
Elimination of the factors that caused the blood flow disorder is carried out in a conservative and operative way. The choice of treatment method depends on the cause that led to the development of spinal stroke. If the lumen of a blood vessel is blocked by a thrombus, then antiplatelet agents (acetylsalicylic acid, dipyridamole) and anticoagulants (heparin) are prescribed. If the cause of a spinal stroke was the compression of an artery by an intervertebral hernia, then in this case, wearing orthopedic corsets, physical therapy, physiotherapy will help restore blood circulation.
If conservative treatment is ineffective, surgical intervention is indicated. It is also necessary when blood vessels are compressed by tumors of the spine and spinal cord. Restoration of lost spinal functions is carried out at the stage of reverse development and includes manual therapy, massage, physiotherapy, physical therapy, spa treatment.
Prognosis and prevention
The prognosis for ischemic spinal stroke depends on the area of the damaged area of the spinal cord and its location. In 50% of cases, with timely medical care and competently conducted rehabilitation, one can expect an almost complete recovery of the patient or a significant recovery of lost functions.
In other cases, patients who have suffered a spinal stroke have persistent neurological disorders (paresis, paralysis, urination and defecation disorders), which cause a person to be recognized as disabled. Deaths are usually observed with large inoperable tumors of the spine, severe aortic injuries, as well as with the addition of complications from the heart (myocardial infarction) and the urinary system (urosepsis).
Prevention of ischemic spinal stroke is carried out in the following directions: early detection and treatment of heart and vascular diseases; control of blood cholesterol and prevention of atherosclerosis; prevention and timely treatment of spinal osteochondrosis, including its complications such as protrusion and herniated disc; immediate medical attention if at least one precursor of spinal stroke appears; a mobile lifestyle and the fight against obesity.