Distsirkulyatorny encephalopathy — the damage of a brain resulting from the chronic slowly progressing violation of brain blood circulation of various etiology. Distsirkulyatorny encephalopathy is shown by a combination of violations of cognitive functions to frustration of motive and emotional spheres. Depending on expressiveness of these manifestations distsirkulyatorny encephalopathy is divided into 3 stages. The list of the examinations conducted at distsirkulyatorny encephalopathy includes an oftalmoskopiya, EEG, REG, Ekho-EG, UZGD and duplex scanning of cerebral vessels, brain MRT. Distsirkulyatorny encephalopathy is treated by individually picked up combination of hypotensive, vascular, antiagregantny, neurotyre-tread and other medicines.
Distsirkulyatorny encephalopathy (DEP) is a widespread disease in neurology. According to statistical data distsirkulyatorny encephalopathy suffer from about 5-6% of the population of Russia. Together with acute strokes, malformation and aneurisms of vessels of a brain of DEP treats vascular neurologic pathology in which structure wins first place on occurrence frequency.
Traditionally distsirkulyatorny encephalopathy is considered a disease of mainly advanced age. However the general tendency to "rejuvenescence" of cardiovascular diseases is noted also concerning DEP. Along with stenocardia, a myocardial infarction, a brain stroke, distsirkulyatorny encephalopathy is even more often observed at persons aged up to 40 years.
Reasons of distsirkulyatorny encephalopathy
The chronic ischemia of a brain resulting from various vascular pathology is the cornerstone of development of DEP. Approximately in 60% of cases distsirkulyatorny encephalopathy is caused by atherosclerosis, namely atherosclerotic changes in walls of brain vessels. The second place among the reasons of DEP is taken by chronic arterial hypertension which is observed at a hypertension, a chronic glomerulonefrit, a polikistoza of kidneys, a feokhromotsitoma, Itsenko-Cushing's disease, etc. At a hypertension distsirkulyatorny encephalopathy develops as a result of a spastic condition of vessels of the brain bringing in impoverishment of a brain blood-groove.
Distinguish pathology of the vertebral arteries providing up to 30% of brain blood circulation from the reasons for which distsirkulyatorny encephalopathy develops. The clinic of a syndrome of a vertebral artery includes also displays of distsirkulyatorny encephalopathy in the vertebro-bazilyarny pool of a brain. Can be the reasons of the insufficient blood-groove on vertebral arteries conducting to DEP: backbone osteochondrosis, instability of cervical department of displastichesky character or after the postponed vertebral trauma, Kimerli's anomaly, malformations of a vertebral artery.
Often distsirkulyatorny encephalopathy arises against the background of diabetes, especially when it is not possible to hold blood sugar indicators at the level of the upper bound of norm. The diabetic macrovascular disease leads to emergence of symptoms of DEP in such cases. Among other causal factors of distsirkulyatorny encephalopathy it is possible to call craniocereberal injuries, system vaskulita, hereditary angiopatiya, arrhythmias, persistent or frequent arterial hypotonia.
Mechanism of development of distsirkulyatorny encephalopathy
Etiologichesky factors of DEP one way or another lead to deterioration in brain blood circulation, so to a hypoxia and violation traffic of cells of a brain. Death of brain cages with formation of sites of depression of brain fabric (leykoareoz) or the multiple small centers of so-called "mute heart attacks" results.
White substance of deep departments of a brain and subcrustal structures are the most vulnerable at chronic violation of brain blood circulation. It is connected with their arrangement on border of vertebro-bazilyarny and carotid pools. Chronic ischemia of deep departments of a brain leads to the violation of communications between subcrustal gangliya and a cerebral cortex which received the name "dissociation phenomenon". On modern representations "the dissociation phenomenon" is the main pathogenetic mechanism of development of distsirkulyatorny encephalopathy and causes its main clinical symptoms: cognitive frustration, violations of the emotional sphere and motive function. It is characteristic that distsirkulyatorny encephalopathy at the beginning of the current is shown by functional violations which at correct treatment can have reversible character, and then the resistant neurologic defect often leading to the patient's invalidization is gradually formed.
It is noted that approximately in half of cases distsirkulyatorny encephalopathy proceeds in combination with neurodegenerate processes in a brain. It is explained by a community of the factors leading to development of both vascular diseases of a brain, and degenerate changes of brain fabric.
Classification of distsirkulyatorny encephalopathy
On an etiology distsirkulyatorny encephalopathy is subdivided on hypertensive, atherosclerotic, venous and mixed. On character of a current (classical), remittiruyushchy and quickly progressing (galloping) distsirkulyatorny encephalopathy which is slowly progressing is allocated.
Depending on weight of clinical manifestations distsirkulyatorny encephalopathy is classified at a stage. Distsirkulyatorny encephalopathy of the I stage differs in subjectivity of the majority of manifestations, easy cognitive violations and lack of changes in the neurologic status. Distsirkulyatorny encephalopathy of the II stage is characterized by obvious cognitive and motive frustration, aggravation of violations of the emotional sphere. Distsirkulyatorny encephalopathy of the III stage is in fact the vascular dementia of various degree of expressiveness which is followed by different motive and mental violations.
Initial displays of distsirkulyatorny encephalopathy
The hardly noticeable and gradual beginning of distsirkulyatorny encephalopathy is characteristic. In an initial stage of DEP to the forefront there can be frustration of the emotional sphere. Approximately at 65% of patients with distsirkulyatorny encephalopathy it is a depression. Distinctive feature of a vascular depression is that patients are not inclined to complain of the lowered mood and depression. More often, it is similar sick ipokhondrichesky neurosis, patients with DEP are fixed on various discomfortable feelings of somatic character. Distsirkulyatorny encephalopathy in such cases proceeds with complaints to pains in a back, an artralgiya, headaches, a ring or noise in the head, pain in various bodies and other manifestations which not absolutely keep within clinic of the somatic pathology which is available for the patient. Unlike depressive neurosis, the depression at distsirkulyatorny encephalopathy arises against the background of the insignificant psychoinjuring situation or at all without the reason, will badly respond to drug treatment antidepressants and psychotherapy.
Distsirkulyatorny encephalopathy of an initial stage can be expressed in the increased emotional lability: irritability, sharp differences of mood, cases of uncontrollable crying in an insignificant occasion, attacks of the aggressive attitude towards people around. Similar manifestations, along with complaints of the patient to fatigue, sleep disorders, headaches, absent-mindedness, initial distsirkulyatorny encephalopathy is similar to a neurasthenia. However the combination of these symptoms to signs of violation of kongnitivny functions is typical for distsirkulyatorny encephalopathy.
In 90% of cases cognitive violations are shown at the most initial stages of development of distsirkulyatorny encephalopathy. Treat them: violation of ability to concentrate attention, a memory impairment, difficulties at the organization or planning of any activity, decrease in rate of thinking, fatigue after intellectual loading. Violation of reproduction of the obtained information at safety of memory of life events is typical for DEP.
The motive violations accompanying an initial stage of distsirkulyatorny encephalopathy include mainly complaints to dizziness and some instability when walking. Nausea and vomiting, but unlike a true vestibular ataxy can be noted, they, as well as dizziness, appear only when walking.
Symptoms of distsirkulyatorny encephalopathy of the II-III stage
Distsirkulyatorny encephalopathy of the II-III stage is characterized by increase of cognitive and motive violations. It is noted a considerable memory impairment, a lack of attentiveness, intellectual decrease, the expressed difficulties to perform feasible earlier mental work if necessary. At the same time patients with DEP are not capable to estimate adequately the condition, overestimate the working capacity and intellectual opportunities. Over time patients with distsirkulyatorny encephalopathy lose ability to generalization and development of the action program, begin to be guided badly in time and the place. In the third stage of distsirkulyatorny encephalopathy the expressed violations of thinking and a praksis, frustration of the personality and behavior are noted. Dementia develops. Patients lose ability to conduct work, and at deeper violations lose also skills of self-service.
From violations of the emotional sphere distsirkulyatorny encephalopathy of later stages most often is followed by apathy. Loss of interest in former hobbies, lack of motivation to any occupation is observed. At distsirkulyatorny encephalopathy of the III stage patients can be busy with any unproductive activity, and nothing is more often in general do. They are indifferent to themselves and the events which are taking place around them.
Hardly noticeable motive violations in the I stage of distsirkulyatorny encephalopathy, in the subsequent become obvious to people around. Are typical for DEP the slowed-down walking with small steps which is followed by a shuffling because the patient does not manage to tear off foot from a floor. Such shuffling gait at distsirkulyatorny encephalopathy received the name "gait of the skier". It is characteristic that when walking it is difficult for patient to begin advance with DEP and also it is difficult to stop. These manifestations, as well as gait of sick DEP, have considerable similarity to clinic of a disease of Parkinson, however unlike it are not followed by motive violations in hands. In this regard to parkinsonism clinical displays of distsirkulyatorny encephalopathy clinical physicians call similar "parkinsonism of a lower body" or "vascular parkinsonism".
In the III stage of DEP symptoms of oral automatism, heavy violations of the speech, a tremor, paresis, a psevdobulbarny syndrome, an urine incontience are observed. Emergence of epileptic attacks is possible. Often distsirkulyatorny encephalopathy of the II-III stage is followed by falling when walking, especially at a stop or turn. Such falling can come to an end with fractures of extremities, especially at DEP combination to osteoporosis.
Diagnosis of distsirkulyatorny encephalopathy
Indisputable value has the identification of symptoms of distsirkulyatorny encephalopathy allowing to begin in due time vascular therapy of the available violations of brain blood circulation earlier. For this purpose periodic survey of the neurologist is recommended to all patients who are in risk group of development of DEP: to hypertensive persons, diabetics and persons with atherosclerotic changes. And it is possible to carry all patients of advanced age to the last group. As kongnitivny violations by which distsirkulyatorny encephalopathy of initial stages is followed can remain the unnoticed patient and his family, their identification requires conducting special diagnostic tests. For example, to the patient suggest to repeat the words pronounced by the doctor, to draw the dial with the shooters specifying the set time and then to remember words which he repeated after the doctor.
Within diagnosis of distsirkulyatorny encephalopathy consultation of the ophthalmologist with an oftalmoskopiya and definition of fields of vision, EEG, Ekho-EG and REG is held. In detection of vascular disorders at DEP UZDG of vessels of the head and a neck, duplex scanning and MRA of brain vessels is important. Carrying out MRT of a brain helps to differentiate distsirkulyatorny encephalopathy with cerebral pathology of other genesis: Alzheimer's disease, disseminated encephalomyelitis, Kreyttsfeldt's disease — Jacoba. The most reliable symptom of distsirkulyatorny encephalopathy is detection of the centers of "mute" heart attacks while signs of a brain atrophy and sites of a leykoareoz can be observed also at neurodegenerate diseases.
Diagnostic search of the etiologichesky factors which caused development of distsirkulyatorny encephalopathy includes consultation of the cardiologist, measurement HELL, a koagulogramma, definition of cholesterol and lipoproteid of blood, the analysis on blood sugar. If necessary to patients with DEP consultation of the endocrinologist, daily monitoring HELL, consultation of the nephrologist, for diagnosis of arrhythmia — the ECG and daily monitoring of the ECG is appointed.
Treatment of distsirkulyatorny encephalopathy
The most effective concerning distsirkulyatorny encephalopathy is complex etiopatogenetichesky treatment. It has to be directed to compensation of the available causal disease, improvement of microcirculation and cerebral blood circulation, and also to protection of nervous cages against a hypoxia and ischemia.
Etiotropny therapy of distsirkulyatorny encephalopathy can include individual selection of hypotensive and antihyperglycemic means, an anti-sclerous diet and so forth. If distsirkulyatorny encephalopathy proceeds against the background of the high rates of cholesterol of blood which are not decreasing at observance of a diet, then include the medicines reducing cholesterol in treatment of DEP (, gemfibrozit, probucol).
The basis of pathogenetic treatment of distsirkulyatorny encephalopathy is made by the medicines which are improving cerebral haemo dynamics and not resulting in effect of "burglarizing". Blockers of calcic channels (nifedipine, , ), fosfodiesteraza inhibitors (, a ginkgo of a bilob), antagonists of a2-adrenoceptors concern to them (piribedit, ). As distsirkulyatorny encephalopathy often is followed by the increased aggregation of platelets, almost lifelong reception of antiagregant is recommended to patients with DEP: acetilsalicylic acid or a tiklopidin, and in the presence of contraindications to them (stomach ulcer, ZhK bleeding and so forth) — a dipiridamola.
Important part of therapy of distsirkulyatorny encephalopathy is made by the medicines with neurotyre-tread effect increasing ability of neurons to function in the conditions of a chronic hypoxia. From such medicines to patients with distsirkulyatorny encephalopathy appoint derivatives of a pirrolidon (piracetam and ), derivative GAMK (N - nicotinoyl - gamma aminobutirovaya acid, gamma aminooleic acid, aminofenilmaslyany acid), medicines of an animal origin (haemo dialyzate from blood of dairy calfs, a cerebral hydrolyzate of a pig, ), membrane stabilizing medicines (it is well-cared ), cofactors and vitamins.
In cases when distsirkulyatorny encephalopathy is caused by the narrowing of a gleam of an internal carotid reaching 70% and it is characterized by bystry progressing, episodes of PNMK or a small stroke, expeditious treatment of DEP is shown. At a stenosis operation consists in a carotid endarterektomiya, at full occlusion — in formation extra- an anastomoza. If distsirkulyatorny encephalopathy is caused by anomaly of a vertebral artery, then reconstruction is carried out it.
Forecast and prevention of distsirkulyatorny encephalopathy
In most cases timely adequate and regular treatment is capable to slow down progressing of encephalopathy of I and even the II stage. Bystry progressing at which each subsequent stage develops in 2 years from previous is in some cases observed. An adverse predictive sign is the combination of distsirkulyatorny encephalopathy to degenerate changes of a brain, and also hypertensive crises occurring against the background of DEP, sharp violations of brain blood circulation (TIA, ischemic or hemorrhagic strokes), badly controlled hyperglycemia.
The best prevention of development of distsirkulyatorny encephalopathy is correction of the available violations of lipidic exchange, fight against atherosclerosis, effective hypotensive therapy, adequate selection of antihyperglycemic treatment for diabetics.