Chronic ischemia of a brain
Chronic ischemia of a brain – the tserebrovaskulyarny insufficiency caused by the progressing deterioration in blood supply of tissue of brain. The clinical picture of chronic ischemia of a brain consists of headaches, dizzinesses, decrease in cognitive functions, emotional lability, motive and coordination violations. The diagnosis is exposed on the basis of symptomatology and data of UZDG/UZDS of vessels of a brain, KT or MPT of a brain, a gemostaziogramma research. Therapy of chronic ischemia of a brain assumes performing hypotensive, gipolipidemichesky, antiagregantny therapy; if necessary surgical tactics is chosen.
Chronic ischemia of a brain
Chronic ischemia of a brain — slowly progressing brain dysfunction which arose owing to diffusion and/or melkoochagovy damage of brain fabric to conditions it is long the existing insufficiency of cerebral blood supply. Enter the concept "chronic ischemia of a brain": distsirkulyatorny encephalopathy, chronic ischemic disease of a brain, vascular encephalopathy, tserebrovaskulyarny insufficiency, atherosclerotic encephalopathy, vascular (atherosclerotic) secondary parkinsonism, vascular dementia, vascular (late) epilepsy. From above-mentioned names most often in modern neurology the term "distsirkulyatorny encephalopathy" is used.
Among the major etiologichesky factors consider atherosclerosis and arterial hypertension, quite often reveal a combination of these two states. Can lead to chronic ischemia of brain blood circulation also other cardiovascular diseases which are especially followed by symptoms of chronic heart failure, violation of a warm rhythm (both constant, and paroksizmalny forms of arrhythmia) which are quite often leading to falling of system haemo dynamics. Value and anomaly of vessels of a brain, neck, a humeral belt, an aorta (especially has its arches) which cannot be shown before development in these vessels of the atherosclerotic, hypertensive or other acquired process.
Recently the big part in development of chronic ischemia of a brain is assigned to venous pathology, not only intra-, but also ekstrakranialny. In formation of chronic ischemia of a brain compressions of vessels, both arterial, and venous are capable to play a part. It is necessary to consider not only spondilogennny influence, but also a sdavleniye by the changed next structures (muscles, tumors, aneurisms). One more reason of development of chronic ischemia of a brain can become cerebral (at elderly patients).
Clinically revealed encephalopathy happens, as a rule, the mixed etiology. In the presence of major factors of development of chronic ischemia of a brain all other variety of the reasons of this pathology can be treated as the additional reasons. Allocation of the additional factors considerably burdening the course of chronic ischemia of a brain is necessary for development of the correct concept of etiopatogenetichesky and symptomatic treatment.
Main reasons for chronic ischemia of a brain: atherosclerosis and arterial hypertension. Additional reasons of chronic ischemia of a brain: cardiovascular diseases (with signs of CSU); violation of a warm rhythm, anomaly of vessels, hereditary angiopatiya, venous pathology, compression of vessels, arterial hypotension, cerebral , system vaskulita, diabetes, blood diseases.
In recent years consider 2 main pathogenetic options of chronic ischemia of a brain based on the following morphological features: nature of damage and primary localization. At bilateral diffusion defeat of white substance allocate leykoentsefalopaticheskiya (or subkortikalny bisvangerovskiya) option of distsirkulyatorny encephalopathy. The second — lacunary option with existence of the multiple lacunary centers. However in practice the mixed options very often meet.
The lacunary option is often caused by direct occlusion of small vessels. In pathogenesis of diffusion defeat of white substance the leading role is played by repeated episodes of falling of system haemo dynamics — arterial hypotension. HELL inadequate antigipertenzivny therapy, decrease in warm dumping can be the cause of falling. Besides persistent cough, surgical interventions, orthostatic hypotension (are of great importance at vegeto-vascular dystonia).
In the conditions of chronic hypoperfusion — the main pathogenetic link of chronic ischemia of a brain — there is exhaustion of mechanisms of compensation, power providing a brain decreases. First of all functional frustration, and then irreversible morphological violations develop: delay of a brain blood-groove, decrease in level of glucose and oxygen in blood, an oxidatic stress, capillary , tendency to a tromboobrazovaniye, depolarization of cellular membranes.
The main clinical displays of chronic ischemia of a brain are poliformny motive frustration, a memory impairment and abilities to training, violations in the emotional sphere. Clinically features of chronic ischemia of a brain — the progressing current, staging, a sindromalnost. It should be noted inverse relation between existence of the complaints which are especially reflecting ability to cognitive activity (attention, memory) and degree of expressiveness of chronic ischemia of a brain: the more cognitive functions suffer, the it is less than complaints. Thus, subjective manifestations in the form of complaints cannot reflect either weight, or the nature of process.
Now the cognitive violations revealed already in the I stage and which are progressively accruing to the III stage are recognized as a kernel of a clinical picture of distsirkulyatorny encephalopathy. In parallel emotional frustration (inertness, emotional lability, loss of interests), various motive violations (from programming and control before execution as difficult neokinetic, highest automated, conceal simple reflex movements) develop.
Stages of distsirkulyatorny encephalopathy
I stage. The above-stated complaints are combined with diffusion microfocal neurologic symptomatology in the form of an anizorefleksiya, not rough reflexes of oral automatism. Easy changes of gait (slowness of walking, small steps), decrease in stability and uncertainty when performing koordinatorny tests are possible. Quite often note emotional and personal violations (irritability, emotional lability, disturbing and depressive lines). Already in this stage there are easy cognitive frustration of neurodynamic type: exhaustion, fluctuation of attention, delay and inertness of intellectual activity. Patients cope with the neuropsychological tests and work in which the accounting of time of performance is not required. Activity of patients is not limited.
II stage. It is characterized by increase of neurologic symptomatology with possible formation of poorly expressed, but dominating syndrome. Come to light separate extrapyramidal violations, an incomplete psevdobulbarny syndrome, an ataxy, ChN dysfunction on the central type (prozo-and ). Complaints become less expressed and not such significant for the patient. Emotional frustration are aggravated. Cognitive function accrues to degree moderate, neurodynamic violations are supplemented dizregulyatorny (a frontal and subcrustal syndrome). Ability to plan and control the actions worsens. Performance of tasks, unlimited is broken by time frames, but ability to compensation remains (an opportunity to use hints remains). Manifestation of signs of decrease in social and professional adaptation is possible.
III stage. Differs in bright manifestation of several neurologic syndromes. Walking and balance (frequent falling), an urine incontience, a parkinsonichesky syndrome is broken. In connection with decrease in criticism to the state the volume of complaints decreases. Behavioural and personal frustration are shown in the form of explosiveness, a rastormozhennost, an apatiko-abulichesky syndrome and psychotic frustration. On a row with neurodynamic and dizregulyatorny cognitive syndromes there are operational frustration (violation of the speech, memory, thinking, a praksis) which can develop into dementia. In such cases patients are slowly deadapted that is shown in professional, social and even daily activity. Disability is quite often stated. Over time ability to self-service is lost.
The following components of the anamnesis are characteristic of chronic ischemia of a brain: a myocardial infarction, coronary heart disease, stenocardia, arterial hypertension (with damage of kidneys, hearts, retinas, a brain), atherosclerosis of peripheral arteries of extremities, diabetes. Fizikalny examination is conducted for detection of pathology of cardiovascular system and includes: definition of safety and symmetry of a pulsation in vessels of extremities and the heads, measurement HELL on all 4 extremities, an auskultation of heart and belly aorta for identification of violations of a warm rhythm.
The purpose of laboratory researches is definition of the reasons of development of chronic ischemia of a brain and its pathogenetic mechanisms. Performing the general blood test, PTI, determination of level of sugar of blood, a lipidic range is recommended. For definition of extent of defeat of substance and vessels of a brain, and also detection of background diseases carrying out the next tool researches is recommended: ECG, oftalmoskopiya, echocardiography, spondilografiya of cervical department, UZDG of the main arteries of the head, duplex and tripleksny scanning of extra-and intrakranialny vessels. Carrying out an angiography of vessels of a brain is in rare instances shown (for detection of anomaly of vessels).
The above-stated complaints characteristic of chronic ischemia of a brain can arise also at various somatic diseases, oncological processes. Besides, such complaints are included often into simptomokompleks of boundary mental disorders and endogenous mental processes. Great difficulties are caused by differential diagnosis of chronic ischemia of a brain with various neurodegenerate diseases to which cognitive frustration and any focal neurologic manifestations are, as a rule, peculiar. Treat such diseases the progressing nadjyaderny paralysis, a kortikobazalny degeneration, a multisystem atrophy, Parkinson's disease, Alzheimer's disease. Besides, often it is necessary to differentiate chronic ischemia of a brain from a tumor of a brain, normotenzivny hydrocephaly, an idiopathic disbaziya and an ataxy.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
The purpose of treatment of chronic ischemia of brain blood circulation is stabilization of destructive process of an ishemization of a brain, stay of rates of progressing, activation of sanogenetichesky mechanisms of compensation of functions, prevention of an ischemic stroke (both primary, and repeated), and also therapy of the accompanying somatic processes.
Chronic ischemia of a brain is not considered the absolute indication to hospitalization in case its current was not complicated by development of a stroke or heavy somatic pathology. Moreover, in the presence of cognitive frustration withdrawal of the patient from his usual situation is capable to aggravate the course of a disease. Treatment of patients with chronic ischemia of a brain it has to be carried out by the neurologist in out-patient and polyclinic conditions. On reaching a tserebrovaskulyarny disease of the III stage patronage is recommended.
Drug treatment of chronic ischemia of a brain is carried out in two directions. The first — normalization of perfusion of a brain by impact on different levels of cardiovascular system. The second — influence on a trombotsitarny link of a hemostasis. Both directions promote optimization of a brain blood-groove, carrying out at the same time and neuroprotective function.
Hypotensive therapy. Maintenance adequate HELL plays a large role in the prevention and stabilization of chronic ischemia of a brain. At purpose of antigipertenzivny medicines it is necessary to avoid sharp fluctuations HELL as at development of chronic ischemia of a brain mechanisms of an autoregulyation of a brain blood-groove fall apart. It is necessary to distinguish two pharmacological groups from the antigipertenzivny medicines developed and introduced in clinical practice — inhibitors angiotensin - the turning enzyme and antagonists of receptors of angiotensin II. Both those, and others render not only angiogipertenzivny, but also angioprotektorny action, protecting the target organs suffering at an arterial hypertension (heart, kidneys, a brain). Antigipertenzivny efficiency of the specified groups of medicines increases at their combination with other hypotensive means (, ).
Gipolipidemichesky therapy. To patients with atherosclerotic defeat of vessels of a brain and a dislipidemiya except a diet (restriction of animal fats), it is expedient to appoint gipolipidemichesky means (statins — , ). Except the main action they promote function improvement an endoteliya, to reduction of viscosity of blood, render antioxidant effect.
Antiagregantny therapy. Chronic ischemia of a brain is accompanied by activation of a trombotsitarno-vascular link of a hemostasis therefore purpose of antiagregantny medicines, for example, of acetilsalicylic acid is required. If necessary other antiagregant add to treatment (klopidogret, ).
Medicines of the combined action. Considering a variety of the mechanisms which are the cornerstone of chronic ischemia of a brain except the basic therapy described above to patients appoint the means normalizing the rheological properties of blood, venous outflow, microcirculation having angioprotektorny and neurotrophic properties. For example: (150-300 mg/days); extract of leaves of a ginkgo of a bilob (120-180 mg/days); cinnarizine + piracetam (75 mg and 1,2 g/days respectively); piracetam + (1,2 g and 15 mg/days respectively); (15-30 mg/days); (300 mg/days). The listed medicines are appointed twice a year courses for 2-3 months.
Surgical treatment. At chronic ischemia of a brain the indication to surgical intervention it is considered to be development of okklyuzivno-stenoziruyushchy damage of the main arteries of the head. In such cases perform reconstructive internal carotid operations — a carotid endarterektomiya, stenting of carotids.
Forecast and prevention
Timely diagnosing and purpose of adequate treatment are capable to suspend progressing of chronic ischemia of a brain. In case of heavy the course of the disease burdened by the accompanying pathologies (a hypertension, diabetes etc.) is noted decrease in working ability of the patient (up to an invalidization).
The preventive measures preventing developing of chronic ischemia of a brain need to be carried out, since early age. Risk factors: obesity, hypodynamia, abuse of alcohol, smoking, stressful situations, etc. Treatment of such diseases as a hypertension, diabetes, atherosclerosis should be carried out only under observation of the specialist doctor. At the first displays of chronic ischemia of a brain it is necessary to limit consumption of alcohol and tobacco, to reduce the volume of physical activities, to avoid long stay in the sun.