Stroke is an acute violation of cerebral circulation, leading to persistent focal brain damage. It may be ischemic or hemorrhagic in nature. Most often, stroke is manifested by sudden weakness in the extremities according to the hemitype, facial asymmetry, disorder of consciousness, speech and vision disorders, dizziness, ataxia. Stroke can be diagnosed based on a combination of data from clinical, laboratory, tomographic and vascular studies. Treatment consists in maintaining the vital activity of the body, correcting cardiac, respiratory and metabolic disorders, combating cerebral edema, specific pathogenetic, neuroprotective and symptomatic therapy, preventing complications.
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Stroke is an acute vascular catastrophe that occurs as a result of vascular diseases or abnormalities of the vessels of the brain. In the USA, the incidence reaches 3 cases per 1 thousand population. Strokes account for 23.5% of the total mortality of the US population and almost 40% of deaths from diseases of the circulatory system. Up to 80% of stroke patients have persistent neurological disorders that cause disability. About a quarter of these cases are deep disability with loss of self-service capability. In this regard, timely provision of adequate emergency medical care for stroke and full-fledged rehabilitation are among the most important tasks of the healthcare system, clinical neurology and neurosurgery.
There are 2 main types of stroke: ischemic and hemorrhagic. They have a fundamentally different mechanism of development and need radically different approaches to treatment. Ischemic and hemorrhagic stroke occupy 80% and 20% of the total number, respectively. Ischemic stroke (cerebral infarction) is caused by a violation of the patency of the cerebral arteries, leading to prolonged ischemia and irreversible changes in brain tissues in the blood supply area of the affected artery. Hemorrhagic stroke is caused by a pathological (atraumatic) rupture of a cerebral vessel with hemorrhage into cerebral tissues. Ischemic stroke is more often observed in people over 55-60 years of age, and hemorrhagic stroke is characteristic of a younger category of the population (more often 45-55 years).
The most significant factors in the occurrence of stroke are arterial hypertension, coronary heart disease and atherosclerosis. Improper nutrition, dyslipidemia, nicotine addiction, alcoholism, acute stress, adynamia, oral contraceptives contribute to the development of both types. At the same time, eating disorders, dyslipidemia, hypertension and adynamia do not have gender differences. The risk factor occurring mainly in women is obesity, in men — alcoholism. The risk of stroke is increased in those persons whose relatives have suffered a vascular catastrophe in the past.
Ischemic stroke develops due to a violation of the passage of blood through one of the blood vessels supplying the brain. Moreover, we are talking not only about intracranial, but also about extracranial vessels. For example, occlusion of the carotid arteries causes about 30% of cases of ischemic stroke. The cause of a sharp deterioration in cerebral blood supply may be vascular spasm or thromboembolism. The formation of thromboembolism occurs in cardiac pathology: after a myocardial infarction, atrial fibrillation, valvular acquired heart defects (for example, rheumatism). Blood clots formed in the heart cavity with blood flow move into the cerebral vessels, causing their blockage. An embolus may be a part of an atherosclerotic plaque detached from the vascular wall, which, falling into a smaller cerebral vessel, leads to its complete occlusion.
The occurrence of hemorrhagic stroke is mainly associated with diffuse or isolated cerebral vascular pathology, as a result of which the vascular wall loses its elasticity and becomes thinner. Similar vascular diseases are: atherosclerosis of cerebral vessels, systemic vasculitis and collagenosis (Wegener’s granulomatosis, SLE, nodular periarteritis, hemorrhagic vasculitis), vascular amyloidosis, angiitis in cocaine addiction and other types of drug addiction. Hemorrhage may be caused by a developmental anomaly with the presence of arteriovenous malformation of the brain. A change in the section of the vascular wall with loss of elasticity often leads to the formation of an aneurysm — bulging of the artery wall. In the aneurysm area, the vessel wall is very thin and easily ruptured. The rupture is facilitated by an increase in blood pressure. In rare cases, hemorrhagic stroke is associated with impaired blood clotting in hematological diseases (hemophilia, thrombocytopenia) or inadequate therapy with anticoagulants and fibrinolytics.
Strokes are divided into 2 large groups: ischemic and hemorrhagic. Depending on the etiology, the first ones can be cardioembolic (occlusion is caused by a thrombus formed in the heart), atherothrombotic (occlusion is caused by elements of an atherosclerotic plaque) and hemodynamic (caused by vascular spasm). In addition, there is a lacunar infarction of the brain caused by a blockage of the cerebral artery of a small caliber, and a small stroke with a complete regression of the neurological symptoms that have arisen in the period up to 21 days since the vascular catastrophe.
Hemorrhagic stroke is classified into parenchymal hemorrhage (bleeding into the brain substance), subarachnoid hemorrhage (bleeding into the subarachnoid space of the cerebral membranes), hemorrhage into the ventricles of the brain and mixed (parenchymal-ventricular, subarachnoid-parenchymal). The most severe course has a hemorrhagic stroke with a breakthrough of blood into the ventricles.
During a stroke, there are several stages: the acute period (the first 3-5 days), the acute period (the first month), the recovery period: early — up to 6 months and late — from 6 to 24 months. Neurological symptoms that have not regressed within 24 months from the onset of stroke are residual (persistently preserved). If the symptoms of a stroke completely disappear in the period up to 24 hours from the beginning of its clinical manifestations, then we are not talking about a stroke, but about a transient violation of cerebral circulation (transient ischemic attack or hypertensive cerebral crisis).
The stroke clinic consists of cerebral, meningeal (shell) and focal symptoms. Acute manifestation and rapid progression of the clinic are characteristic. Usually, ischemic stroke has a slower development than hemorrhagic stroke. Focal manifestations come to the fore from the onset of the disease, general cerebral symptoms are usually mild or moderate, meningeal symptoms are often absent. Hemorrhagic stroke develops more rapidly, debuts with cerebral manifestations, against which focal symptoms appear and progressively increase. In the case of subarachnoid hemorrhage, meningeal syndrome is typical.
General cerebral symptoms are represented by headache, vomiting and nausea, disorder of consciousness (deafness, sopor, coma). Approximately 1 in 10 patients with hemorrhagic stroke has an epiprime. The increase in cerebral edema or the volume of blood spilled during hemorrhagic stroke leads to severe intracranial hypertension, mass effect and threatens the development of dislocation syndrome with compression of the brain stem.
Focal manifestations depend on the location of the stroke. With a stroke, central hemiparesis / hemiplegia occurs in the carotid artery basin — a decrease / complete loss of muscle strength of the limbs on one side of the body, accompanied by an increase in muscle tone and the appearance of pathological stop signs. In the ipsilateral half of the face, paresis of facial muscles develops, which is manifested by facial distortion, lowering of the corner of the mouth, smoothing of the nasolabial fold, logophthalmos; when trying to smile or raise eyebrows, the affected side of the face lags behind the healthy side or remains motionless at all. These motor changes occur in the extremities and half of the face of the contralateral side of the lesion. In the same extremities, sensitivity decreases / drops out. Homonymous hemianopia is possible — loss of the same-named halves of the visual fields of both eyes. In some cases, photopsias and visual hallucinations are noted. Aphasia, apraxia, decreased criticism, visual-spatial agnosia are often observed.
With a stroke in the vertebrobasilar pool, dizziness, vestibular ataxia, diplopia, visual field defects, dysarthria, cerebellar ataxia, hearing disorders, oculomotor disorders, dysphagia are noted. Quite often there are alternating syndromes — a combination of ipsilateral stroke peripheral paresis of cranial nerves and contralateral central hemiparesis. In lacunar stroke, hemiparesis or hemihypesthesia can be observed in isolation.
Differential diagnosis of stroke
The primary task of diagnosis is to differentiate stroke from other diseases that may have similar symptoms. The absence of a traumatic history and external injuries allows to exclude a closed craniocerebral injury. Myocardial infarction with loss of consciousness occurs as suddenly as a stroke, but there are no focal and cerebral symptoms, arterial hypotension is characteristic. A stroke manifesting loss of consciousness and an epiprime can be mistaken for epilepsy. The presence of a neurological deficit, which increases after paroxysm, and the absence of an anamnesis of epiprimes speaks in favor of stroke.
At first glance, toxic encephalopathies are similar to stroke in acute intoxication (carbon monoxide poisoning, liver failure, hyper- and hypoglycemic coma, uremia). Their distinctive feature is the absence or weak manifestation of focal symptoms, often the presence of polyneuropathy, a change in the biochemical composition of the blood corresponding to the nature of intoxication. Stroke-like manifestations can be characterized by hemorrhage into a brain tumor. Without an oncological history, it is clinically impossible to distinguish it from a hemorrhagic stroke. Intense headache, meningeal symptoms, nausea and vomiting in meningitis may resemble a picture of subarachnoid hemorrhage. In favor of the latter, the absence of pronounced hyperthermia may indicate. Migraine paroxysm may have a similar pattern to subarachnoid hemorrhage, but it proceeds without shell symptoms.
Differential diagnosis of ischemic and hemorrhagic stroke
The next stage of differential diagnosis after diagnosis is to determine the type of stroke, which is of paramount importance for differentiated therapy. In the classical version, ischemic stroke is characterized by gradual progression without impaired consciousness at the onset, and hemorrhagic stroke is characterized by apoplectic development with early onset of a disorder of consciousness. However, in some cases, an ischemic stroke may have an atypical onset. Therefore, during the diagnosis, it is necessary to rely on a set of various signs that indicate in favor of a particular type of stroke.
So, for hemorrhagic stroke, it is more typical to have a history of hypertension with hypertensive crises, and for ischemic stroke — arrhythmia, valvular defect, myocardial infarction. The age of the patient also matters. The manifestation of the clinic during sleep or rest speaks in favor of ischemic stroke, in favor of hemorrhagic stroke — the beginning during the period of active activity. The ischemic type of stroke in most cases occurs against the background of normal blood pressure, focal neurological deficit comes to the fore, arrhythmia, deafness of heart tones are often noted. Hemorrhagic stroke, as a rule, debuts with elevated blood pressure with general cerebral symptoms, shell syndrome and vegetative manifestations are often expressed, followed by the addition of stem symptoms.
Instrumental diagnosis of stroke
Clinical diagnostics allows the neurologist to determine the pool in which the vascular catastrophe occurred, localize the focus of cerebral stroke, determine its nature (ischemic / hemorrhagic). However, the clinical differentiation of the type
in 15-20% of cases is erroneous. Instrumental examinations allow to establish a more accurate diagnosis. Urgent MRI or CT of the brain is optimal. Tomography allows you to accurately determine the type of stroke, specify the localization and size of a hematoma or ischemia focus, assess the degree of brain edema and displacement of its structures, identify subarachnoid hemorrhage or blood breakthrough into the ventricles, diagnose stenosis, occlusion and aneurysm of cerebral vessels.
Since there is not always the possibility of urgent neuroimaging, they resort to performing a lumbar puncture. Preliminary Echo-EG is performed to determine / exclude the displacement of the median structures. The presence of displacement is a contraindication for lumbar puncture, threatening in such cases the development of dislocation syndrome. Puncture may be required when clinical data indicate subarachnoid hemorrhage, and tomographic methods do not detect blood accumulation in the subarachnoid space. In ischemic stroke, the pressure of the cerebrospinal fluid is normal or slightly elevated, the examination of the cerebrospinal fluid does not reveal significant changes, a slight increase in protein and lymphocytosis may be detected, in some cases a small admixture of blood. In hemorrhagic stroke, there is an increase in cerebrospinal fluid pressure, a bloody color of the cerebrospinal fluid, a significant increase in protein concentration; in the initial period, unchanged erythrocytes are determined, later xanthochromic.
Ultrasound of extracranial vessels and transcranial ultrasound make it possible to diagnose angiospasm and occlusion, determine the degree of stenosis and assess collateral circulation. Emergency angiography of the brain is necessary to resolve the issue of the expediency of thrombolytic therapy, as well as to diagnose aneurysms. Preference is given to MRI angiography or CT of cerebral vessels. In order to identify the cause of stroke, an ECG, an echocg, a clinical blood test with determination of the number of platelets, a coagulogram, a biochemical blood test (including blood sugar), urine analysis, blood gas composition analysis.
The optimal timing of hospitalization and initiation of therapy is considered to be the first 3 hours from the onset of clinical manifestations. Treatment in the acute period is carried out in intensive care wards of specialized neurological departments, then the patient is transferred to the early rehabilitation unit. Before the type of stroke is established, basic undifferentiated therapy is carried out, after an accurate diagnosis — specialized treatment, and then long-term rehabilitation.
Undifferentiated stroke treatment includes correction of respiratory function with pulse oximetric monitoring, normalization of blood pressure and cardiac activity with daily monitoring of ECG and blood pressure (together with a cardiologist), regulation of homeostatic parameters (electrolytes and blood pH, glucose levels), the fight against cerebral edema (osmodiuretics, corticosteroids, hyperventilation, barbiturate coma, cerebral hypothermia, decompressive trepanation skull, external ventricular drainage).
In parallel, symptomatic therapy is carried out, which may consist of hypothermic agents (paracetamol, naproxen, diclofenac), anticonvulsants (diazepam, lorazepam, valproates, sodium thiopental, hexenal), antiemetic drugs (metoclopramide, perfenazine). With psychomotor agitation, magnesium sulfate, haloperidol, barbiturates are indicated. Basic stroke therapy also includes neuroprotective therapy (thiotriazoline, piracetam, choline alfoscerate, glycine) and prevention of complications: aspiration pneumonia, respiratory distress syndrome, pressure sores, uroinfection (cystitis, pyelonephritis), PE, thrombophlebitis, stress ulcers.
Differentiated treatment of stroke corresponds to its pathogenetic mechanisms. In ischemic stroke, the main thing is to restore the blood flow of the ischemic area as soon as possible. For this purpose, medical and intraarterial thrombolysis is used with the help of a tissue plasminogen activator (rt-PA), mechanical thrombolytic therapy (ultrasound destruction of a blood clot, aspiration of a blood clot under tomographic control). With a proven cardioembolic genesis of stroke, anticoagulant therapy with heparin or nadroparin is performed. If thrombolysis is not indicated or cannot be performed, then antiplatelet drugs (acetylsalicylic acid) are prescribed. Vasoactive agents (vinpocetine, nicergoline) are used in parallel.
The priority in the treatment of hemorrhagic stroke is to stop bleeding. Hemostatic treatment can be carried out with calcium preparations, vikasol, aminocaproic acid, ethamzylate, aprotinin. Together with the neurosurgeon, a decision is made on the expediency of surgical treatment. The choice of surgical tactics depends on the location and size of the hematoma, as well as on the patient’s condition. Stereotactic aspiration of the hematoma or its open removal by trepanation of the skull is possible.
Rehabilitation is carried out with the help of regular courses of nootropic therapy (nicergoline, pyritinol, piracetam, ginkgo biloba, etc.), physical therapy and mechanotherapy, reflexology, electromyostimulation, massage, physiotherapy. Often patients have to rebuild motor skills and learn self-care. If necessary, specialists in the field of psychiatry and psychologists carry out psychocorrection. Correction of speech disorders is carried out by a speech therapist.
Prognosis and prevention
The fatal outcome in the 1st month with ischemic stroke varies from 15 to 25%, with hemorrhagic stroke — from 40 to 60%. Its main causes are edema and dislocation of the brain, the development of complications (PE, acute heart failure, pneumonia). The greatest regression of neurological deficit occurs in the first 3 months. stroke. There is often a worse recovery of movements in the arm than in the leg. The degree of recovery of lost functions depends on the type and severity of stroke, timeliness and adequacy of medical care, age, concomitant diseases. A year after the stroke, the probability of further recovery is minimal, after such a long period, usually only aphasia can be regressed.
The primary prevention of stroke is a healthy diet with a minimum amount of animal fats and salt, a mobile lifestyle, a balanced and calm character that allows you to avoid acute stressful situations, the absence of bad habits. Effective treatment of cardiovascular pathology (correction of blood pressure, therapy of coronary artery disease, etc.), dyslipidemia (taking statins), reduction of excess body weight contributes to the prevention of both primary and recurrent stroke. In some cases, stroke prevention is performed by surgical interventions — carotid endarterectomy, reconstruction of the vertebral artery, formation of extra-intracranial anastomosis, surgical treatment of AVM.