Spinal stroke is an acute violation of spinal circulation with the development of ischemia /hemorrhage. It is manifested by acute motor disorders of the central and peripheral type, a decrease in various types of sensitivity, a disorder of the function of the pelvic organs. The diagnosis is established on the basis of clinical data, the results of tomography, angiography, analysis of cerebrospinal fluid, electroneuromyography. Conservative therapy is carried out differentially according to the type of stroke. Surgical intervention is required to remove a blood clot, aneurysm, and restore the integrity of the vessel.
General information
Spinal stroke is much less common than disorders of cerebral circulation. The reason becomes clear given the ratio of the masses of the spinal cord and brain, which is approximately 1:47. Among all acute hemodynamic disorders of the central nervous system, spinal stroke occurs in 1-1.5% of cases. The disease is most often diagnosed in the age period of 30-70 years. Male and female persons suffer equally often. The vast majority of spinal cord strokes are ischemic in nature. The largest number of lesions occur in the lumbar, lower thoracic spinal segments.
Causes
The main causes of acute disorders of cerebrospinal circulation are thromboembolism, compression, prolonged spasm, rupture of spinal blood supply vessels. The etiofactors provoking vascular catastrophe are numerous and diverse. The versatility of the etiology was the reason for the division of factors causing spinal stroke into two main groups.
Primary vascular lesions:
- Anomalies of spinal vessels: arteriovenous malformations, aneurysms, kinks. They are quite rare. They create obstacles that slow down the blood flow. Thinning of the vascular wall in the area of aneurysm, malformation provokes its rupture with the development of hemorrhagic stroke.
- Vascular wall changes: atherosclerosis, amyloidosis, varicose veins, vasculitis. Atherosclerosis of the aorta and spinal arteries is the most common cause of ischemic spinal stroke. A violation of blood supply occurs due to a decrease in the lumen of the arteries due to the formation of atherosclerotic plaques, blockage of blood vessels detached from the plaque masses.
- Vascular damage. Rupture of the vessel is possible with spinal cord injury, damage to the vascular wall by a fragment due to a fracture of the spine. Iatrogenic injuries are extremely rare, which are a complication of lumbar puncture, spinal anesthesia, surgical interventions in the spine.
Secondary hemodynamic disorders:
- Pathology of the spinal column: malformations of the spine, osteochondrosis, spondylitis, intervertebral hernia, spondylolisthesis. The change in the mutual anatomical arrangement of the structures of the vertebral column due to an anomaly, displacement of the vertebrae causes compression of the spinal vessels. Osteophytes, disc herniation also cause compression of nearby vessels.
- Tumors of the spinal cord and spine. As the neoplasms grow, they put pressure on the vessels passing nearby, reducing their lumen. Malignant tumors are able to germinate the walls of blood vessels, provoke their thinning, destruction, leading to hemorrhage.
- Lesion of the spinal membranes: arachnoiditis, meningitis. The inflammatory process passes to the spinal vessels. Vasculitis leads to increased permeability, impaired elasticity, and the formation of thrombotic deposits in the affected area of the vascular wall.
- Blood diseases: hemophilia, leukemia, coagulopathy, thrombocytemia. Accompanied by a violation of the rheological properties of blood, hemostatic mechanisms. Hemorrhagic spinal stroke occurs due to bleeding with the slightest vascular damage, ischemic — due to increased thrombosis.
In many cases, spinal stroke develops as a result of the implementation of several causes at once. The probability of pathology increases in the presence of contributing circumstances. The most significant predisposing factors are hypertension, obesity, hyperlipidemia, physical inactivity, smoking.
Pathogenesis
The cervical, upper thoracic segments of the spinal cord are supplied with blood by the system of vertebral arteries originating in the subclavian artery. Blood supply from the fourth thoracic segment to the sacral region inclusive is carried out by intercostal, lumbar, sacral vessels coming from the aorta. Blood circulation in the area of the ponytail is provided by the internal iliac artery. Vessels suitable to the spinal cord as part of the spinal roots give rise to radiculomedullary arteries, the number of which varies from 5 to 16. Radiculomedullary vessels form numerous anastomoses forming an anterior spinal artery along the anterior surface of the brain, and 2 posterior arteries along the posterior surface. The variability of the number and location of radiculomedullary arteries causes difficulties in determining the localization of vascular problems.
Local violation of the passage of blood in the vessel (due to blockage, compression, spasm, rupture) causes hypoxia (oxygen starvation), dysmetabolism of neurons in the blood-supplied area, the formation of a hemorrhage zone. In acute development, these disorders do not have time to be compensated by collateral circulation, metabolic restructuring. As a result, there is a dysfunction of the neurons of the area of the cerebrospinal substance. A zone of ischemia / hemorrhage is formed, which subsequently transforms into a zone of necrosis (death of neurons) with the formation of an irreversible neurological deficit.
Classification
Spinal stroke can have several etiopathogenetic variants. Understanding the mechanisms of development that form the basis of a particular case of the disease is of fundamental importance in clinical neurology. In this regard, the main classification of spinal strokes is based on the pathogenetic principle and includes three types of stroke:
- Ischemic (infarction). It is caused by spasm, obliteration, compression of one or several arteries supplying the spinal cord with the formation of an ischemic area in the spinal cord substance.
- Hemorrhagic. Occurs due to rupture, damage to the vessel wall. Hemorrhage in the parenchyma of the spinal cord is called hematomyelia, in the membranes — hematorachis.
- Mixed. Hemorrhage is accompanied by reflex vascular spasm with the formation of a secondary ischemic zone.
According to the morphopathogenetic mechanisms of the development of the disease , four periods are distinguished during its course:
- The harbinger stage. It is characteristic of ischemic stroke. It is manifested by transient episodes of back pain, motor, sensory disorders.
- The stage of stroke development (stroke in progress) is the period of progression of pathological changes: expansion of the ischemic focus, continuation of bleeding. Clinically accompanied by an increase in symptoms.
- The stage of reverse development. Therapeutic measures stop the progression, the restoration of the function of the surviving neurons begins. The severity of neurological deficit is gradually decreasing.
- The stage of residual consequences. It is caused by incomplete restoration of lost functions due to the mass death of neurons. Residual post-stroke symptoms are persistent for life.
Symptoms
Symptoms occur suddenly within a few minutes, less often — hours. Ischemic spinal stroke in some cases has a prodromal period in the form of episodes of intermittent lameness, paresthesia, periodic pain in the spine, symptoms of sciatica, transient pelvic disorders. At the onset of the disease, a gradual increase in symptoms is possible. Pain syndrome is uncharacteristic, on the contrary, the defeat of the sensory zones of the spinal cord leads to the disappearance of pain sensations noted during the period of precursors.
The manifestation of hematomyelia occurs after spinal injury, physical exertion, accompanied by an increase in body temperature. Acute dagger pain in the spinal column is typical, radiating to the sides, often taking on a shingling character. Hematorachis occurs with irritation of the meninges, the spread of the process to the membranes of the brain causes the appearance of cerebral symptoms: cephalgia, dizziness, nausea, depression of consciousness.
Spinal stroke is characterized by a large polymorphism of the clinical picture. Neurological deficit depends on the localization, the prevalence of the process along the diameter of the spinal cord and along its length. Motor disorders are characterized by sluggish peripheral paresis at the level of the lesion, central spastic paresis below the affected segment. Peripheral paresis is accompanied by muscle hypotension, hyporeflexia, which subsequently leads to muscle atrophy. With central paresis, there is spastic muscle hypertonus, hyperreflexia, and the formation of contractures is possible. Localization of the lesion zone in the cervical segments is manifested by sluggish paresis of the upper extremities and spastic lower, in the thoracic segments — central lower paraparesis, in the lumbosacral – peripheral paraparesis.
Sensory disturbances occur below the level of the lesion, depend on the localization of the stroke focus in the diameter of the spinal cord. With an extensive spinal stroke with pathological changes throughout the spinal diameter, there is a loss of all types of sensitivity, pelvic disorders, bilateral motor deficiency. The involvement of half of the diameter leads to the development of Brown-Sekara syndrome: motor disorders, loss of deep sensitivity, heterolateral disorders of surface (pain, temperature) perception are detected homolaterally.
When the ventral half is affected (a catastrophe in the anterior spinal artery), motor disorders are accompanied by loss of pain, urinary retention, feces. Tactile, musculoskeletal perception are preserved. Dorsal stroke (pathology of the posterior spinal artery) is rarely observed, manifested by Williamson syndrome: spastic paresis, sensitive ataxia, segmental hypesthesia, loss of vibration sensitivity of the lower extremities. An isolated lesion of the anterior horn is distinguished by the presence of only a unilateral peripheral paresis.
Complications
Spinal stroke is characterized by motor disorders that transform into persistent limitations of motor function without appropriate treatment. Patients lose the ability to move freely, with spastic paresis, the situation is aggravated by the development of joint contractures. In the case of severe tetraparesis, patients are bedridden. Immobility is dangerous by the development of bedsores, congestive pneumonia. Pelvic disorders are complicated by ascending urinary tract infection: urethritis, cystitis, pyelonephritis. The addition of infectious complications can lead to sepsis with the threat of death.
Diagnostics
Diagnostic measures begin with the collection of anamnesis. The presence of the harbinger stage, acute/subacute onset, the sequence of development of symptoms is important. The motor/sensory deficit revealed during the neurological examination allows the neurologist to assume a topical diagnosis, however, the variety of individual options for spinal blood supply causes difficulties in determining the location of vascular occlusion or rupture. In order to clarify the diagnosis, instrumental studies are conducted:
- Tomography of the spine. Computed tomography allows you to determine the displacement, damage to the vertebrae, the presence of fragments, osteophytes, narrowing of the intervertebral fissure. MRI of the spine better visualizes the spinal cord, makes it possible to diagnose an intervertebral hernia, compression of the spinal canal, spinal tumor, hematoma.
- Lumbar puncture. In 30% of patients, the study of cerebrospinal fluid does not reveal abnormalities. In most patients at the stage of pathology development, an increase in protein concentration to 3 g / l is observed, pleocytosis of 30-150 cells in 1 µl. Hemorrhagic variant is accompanied by the appearance of erythrocytes in the cerebrospinal fluid.
- Spinal angiography. It is carried out to detect aneurysms, malformations, thrombosis, compression of the vessel from the outside. A simpler, but less informative study of spinal circulation in the thoracic and lumbar regions is the ultrasound of the aorta and its branches.
- Electroneuromyography. It is necessary to detect a clinically undiagnosed disorder of the innervation of individual muscles.
To determine the causal background pathology, according to the indications, a therapist, a cardiologist, an endocrinologist, a hematologist are consulted, blood is examined for sugar, lipoprotein levels, cholesterol, and a coagulogram is made. Differential diagnosis is carried out with acute myelitis, spinal cord tumor, infectious myelopathy, syringomyelia, epidural abscess. Differentiation of hemorrhagic and ischemic stroke is important for determining therapeutic tactics.
Treatment
With this disease, urgent therapeutic measures are required. Early initiation of therapy allows you to stop the expansion of the spinal lesion zone, prevent the death of neurons. Comprehensive conservative treatment is carried out, corresponding to the type of stroke:
- Non-specific therapy. It is prescribed regardless of the type of stroke, aimed at reducing edema, maintaining the metabolism of neurons, increasing the resistance of spinal tissues to hypoxia, preventing complications. It is carried out with diuretics (furosemide), neuroprotectors, antioxidants, vitamins of group B.
- Specific therapy of ischemia. Improvement of blood circulation of the ischemic area is achieved by the use of vasodilating, disaggregating, improving microcirculation means. With thromboembolism, anticoagulants are indicated: heparin, nadroparin.
- Specific therapy of hemorrhage. It consists in the use of hemostatic pharmaceuticals: vikasol, epsilonaminocaproic acid. Additionally, angioprotectors are prescribed that strengthen the walls of blood vessels.
In case of rupture of a vessel, compression by a tumor, thromboembolism, surgical treatment is possible. Operations are performed by neurosurgeons, vascular surgeons on an emergency basis. The list of possible surgical interventions includes:
- Reconstructive vascular operations: thromboembolectomy, stenting of the affected vessel, suturing/clipping of a vascular wall defect.
- Elimination of angiodysplasia: excision of malformation, ligation/sclerosis of adductor vessels, resection of aneurysm.
- Elimination of compression: removal of extra-/intramedullary spinal tumor, discectomy for hernia, fixation of the spine.
In the recovery period, rehabilitologists use the entire arsenal of means for the speedy restoration of lost neurological functions. Physical therapy, massage, physiotherapy are prescribed. Electromyostimulation helps to improve the conductivity of nerve fibers, restoration of arbitrary control of urinary function — electrostimulation of the bladder.
Prognosis and prevention
Spinal stroke is not as life-threatening a condition as cerebral stroke. A fatal outcome is possible with malignant neoplasms, a severe general somatic background, and the addition of a secondary infection. Timely treatment contributes to a rapid regression of symptoms. The vastness of the affected area, the late start of treatment, concomitant pathology cause incomplete recovery, disability of the patient due to persistent residual paresis, pelvic, sensitive disorders. Prevention of the disease is based on timely treatment of vascular diseases, detection and removal of malformations, treatment of intervertebral hernias, prevention of spinal injuries. Of great importance is the exclusion of predisposing factors: maintaining an active lifestyle, weight normalization, balanced nutrition, smoking cessation.