Stroke — the sharp violation of brain blood circulation leading to permanent focal damage of a brain. Can have ischemic or hemorrhagic character. Most often the stroke is shown by sudden weakness in extremities on a gemitipa, asymmetry of the person, disorder of consciousness, violation of the speech and sight, dizziness, an ataxy. It is possible to diagnose a stroke on a data set of clinical, laboratory, tomographic and vascular trials. Treatment consists in maintenance of activity of an organism, correction of warm, respiratory and metabolic violations, fight against cerebral hypostasis, specific pathogenetic, neurotyre-tread and symptomatic therapy, the prevention of complications.
Stroke — the sharp vascular accident arising owing to vascular diseases or anomalies of vessels of a brain. In Russia incidence reaches 3 cases on 1 thousand population. 23,5% of the general mortality of the population of Russia and nearly 40% of mortality from blood circulatory system diseases fall to the share of strokes. To 80% of the patients who had a stroke have permanent neurologic violations, causing disability. About a quarter of these cases is made by deep disability with loss of a possibility of self-service. In this regard timely rendering adequate emergency medical care at a stroke and full rehabilitation treat the most important problems of a health system, clinical neurology and neurosurgery.
There are 2 main types of a stroke: ischemic and hemorrhagic. They have essentially different mechanism of development and need cardinally different approaches to treatment. The ischemic and hemorrhagic stroke is occupied by respectively 80% and 20% of the general set of strokes. The ischemic stroke (a brain heart attack) is caused by the violation of passability of cerebral arteries leading to long ischemia and irreversible changes of brain fabrics in a zone of blood supply of the affected artery. The hemorrhagic stroke is caused by a pathological (atraumatic) rupture of a brain vessel with hemorrhage in cerebral fabrics. The ischemic stroke is more often observed at persons is more senior than 55-60-year age, and hemorrhagic is characteristic of younger category of the population (more often 45-55 years).
Arterial hypertension, IBS and atherosclerosis act as the most powerful factors of developing of a stroke. Development of both types of a stroke is promoted by improper feeding, a dislipidemiya, nicotine addiction, alcoholism, acute stress, an adinamiya, reception of oral contraceptives. At the same time violation of food, a dislipidemiya, arterial hypertension and an adinamiya have no gender distinctions. Risk factor, meeting mainly at women, obesity acts, men have an alcoholism. The risk of development of a stroke in those persons whose relatives transferred vascular accident in the past is increased.
The ischemic stroke develops owing to violation of passing of blood on one of krovosnabzhayushchy a brain of blood vessels. And it is not only about intrakranialny, but also and about ekstrakranialny vessels. For example, occlusion of carotids causes about 30% of cases of an ischemic stroke. The vascular spasm or a thrombembolia can act as the reason of sharp deterioration in cerebral blood supply. Formation of tromboembol happens at cardiac pathology: after the postponed myocardial infarction, at vibrating arrhythmia, the valvate acquired heart diseases (for example, at rheumatism). The blood clots created hearts in a cavity with current of blood move to cerebral vessels, causing their obstruction. The part of an atherosclerotic plaque which came off a vascular wall which getting to smaller cerebral vessel can be Embol, leads to its full occlusion.
Developing of a hemorrhagic stroke is connected generally with the diffusion or isolated cerebral pathology of vessels owing to which the vascular wall loses the elasticity and becomes thinner. Similar vascular diseases are: atherosclerosis of vessels of a brain, system vaskulita and collagenases ( Wegener, the hard currency, nodular periarteriit, hemorrhagic vaskulit), vessels, angiit at a kokainomaniye, etc. types of drug addiction. Hemorrhage can be caused by anomaly of development with existence of an arteriovenozny malformation of a brain. Change of the site of a vascular wall with elasticity loss often leads to formation of aneurism — protrusions of a wall of an artery. In the field of aneurism the wall of a vessel is very thinned and is easily broken off. The gap is promoted by rise in arterial pressure. In rare instances the hemorrhagic stroke is connected with violation of fibrillation at hematologic diseases (hemophilia, thrombocytopenia) or inadequate therapy by anticoagulants and fibrinolitika.
Classification of a stroke
Strokes are divided into 2 big groups: ischemic and hemorrhagic. Depending on an etiology the first can be kardioembolichesky (occlusion is caused by the blood clot formed in heart), aterotrombotichesky (occlusion is caused by elements of an atherosclerotic plaque) and haemo dynamic (caused by a vascular spasm). Besides, allocate the lacunary heart attack of a brain caused by obstruction of a cerebral artery of small caliber and a small stroke with full regress of the arisen neurologic symptomatology during the period up to 21 days from the moment of vascular accident.
The hemorrhagic stroke is classified on parenchymatous hemorrhage (bleeding in brain substance), subarakhnoidalny hemorrhage (bleeding in subweb space of cerebral covers), hemorrhage in ventricles of a brain and mixed (parenchymatous , subarakhnoidalno-parenchymatous). The heaviest current has a hemorrhagic stroke with break of blood in ventricles.
During a stroke allocate several stages: the sharpest period (the first 3-5 days), sharp period (first month), recovery period: early — up to 6 months and late — from 6 to 24 months. The neurologic symptoms which did not undergo regress within 24 months since the beginning of a stroke are residual (with firmness remained). If stroke symptoms completely disappear during the period to 24 h from the moment of the beginning of its clinical manifestations, then it is not about a stroke, and about passing violation of brain blood circulation (the tranzitorny ischemic attack or gipertenzivny cerebral crisis).
The clinic of a stroke consists of all-brain, meningealny (obolochechny) and focal symptoms. The sharp demonstration and bystry progressing of clinic is characteristic. Usually ischemic stroke has slower development, than hemorrhagic. To the forefront since the beginning of a disease there are focal manifestations, all-brain symptoms, as a rule, poorly or are moderately expressed, meningealny — often are absent. The hemorrhagic stroke develops more promptly, debuts all-brain manifestations against the background of which it develops and progressively the focal symptomatology accrues. In case of subarakhnoidalny hemorrhage the meningealny syndrome is typical.
All-brain symptoms are presented by a headache, vomiting and nausea, disorder of consciousness (an oglushennost, a sopor, a coma). Approximately at 1 of 10 patients with a hemorrhagic stroke it is observed . Increase of hypostasis of a brain or volume of the blood which streamed at a hemorrhagic stroke leads to sharp intra cranial hypertensia, mass effect and threatens with development of a dislocation syndrome with a sdavleniye of a brain trunk.
Focal manifestations depend on location of a stroke. At a stroke in the pool of carotids there is the central hemiparesis / hemiplegia — the decrease / full loss of muscular force of extremities of one side of a body which is followed by increase in a muscular tone and emergence of pathological-foot signs. In ipsilateralny to extremities to a half of the face paresis of mimic muscles develops that is shown by a distortion of the person, omission of a corner of a mouth, smoothing of a nasolabial fold, logoftalmy; in attempt to smile or raise eyebrows the struck side of a face lags behind from healthy or at all remains motionless. The specified motive changes happen in extremities and a half of the face counterlateral to the center of defeat of the party. In the same extremities sensitivity decreases/drops out. The gomonimny gemianopsiya — loss of the half of the same name of visual fields of both eyes is possible. In some cases fotopsiya and visual hallucinations are noted. Aphasia, apraxia, decrease in criticism, visual and spatial agnosia is often observed.
At a stroke in the vertebrobazilyarny pool dizziness, a vestibular ataxy, a diplopiya, defects of visual fields, a dizartriya, a cerebellar ataxy, disorders of hearing, glazodvigatelny violations, a dysphagy is noted. Rather often there are alternating syndromes — a combination ipsilateralny to a stroke of peripheral paresis of craniocereberal nerves and a counterlateral central hemiparesis. At a lacunary stroke the hemiparesis or a gemigipesteziya can be observed separately.
Diagnosis of a stroke
Differential diagnosis of a stroke
Priority of diagnostics is the stroke differentiation from other diseases which can have similar symptomatology. Lack of the traumatic anamnesis and external damages allows to exclude the closed craniocereberal trauma. The myocardial infarction with loss of consciousness arises as suddenly as a stroke, but at the same time there are no focal and all-brain symptoms, arterial hypotonia is characteristic. The stroke demonstrating loss of consciousness and epipristupy can be taken for epilepsy mistakenly. The stroke is spoken well by existence of the neurologic deficiency increasing after a paroxysm, lack of epipristup in the anamnesis.
Toxic encephalopathies at sharp intoxications are at first sight similar to a stroke (poisoning with carbon monoxide, a liver failure, hyper - and a hypoglycemic coma, uraemia). Their distinctive feature is absence or weak manifestation of focal symptomatology, often the existence of a polyneuropathy corresponding to the nature of intoxication change of biochemical composition of blood. By Insultopodobny manifestations hemorrhage in a brain tumor can be characterized. Without existence of the oncological anamnesis it is not possible to distinguish it from a hemorrhagic stroke clinically. The intensive headache, meningealny symptoms, nausea and vomiting at meningitis can remind a picture of subarakhnoidalny hemorrhage. In favor of the last lack of the expressed hyperthermia can testify. The migraine paroxysm can have a picture, similar to subarakhnoidalny hemorrhage, however it proceeds without obolochechny symptoms.
Difdiagnoz of an ischemic and hemorrhagic stroke
The following stage of differential diagnostics after establishment of the diagnosis is definition of a type of a stroke that has paramount value for performing the differentiated therapy. In classical option the ischemic stroke differs in gradual progressing without violations of consciousness in a debut, and hemorrhagic — apoplektiformny development with early emergence of disorder of consciousness. However in some cases the ischemic stroke can have the atypical beginning. Therefore during diagnostics it is necessary to rely on set of various signs testifying in favor of this or that type of a stroke.
So, existence in the anamnesis of a hypertension with hypertensive crises, and for ischemic — arrhythmias, valvate defect, a myocardial infarction is more typical for a hemorrhagic stroke. Also the age of the patient matters. The ischemic stroke is spoken well by a demonstration of clinic in the period of a dream or rest, in favor of hemorrhagic — the beginning during vigorous activity. The ischemic type of a stroke in most cases arises against the background of normal HELL, to the forefront there is a focal neurologic deficiency, arrhythmia, dullness of warm tones is quite often noted. The hemorrhagic stroke, as a rule, debuts at raised HELL from all-brain symptoms, the obolochechny syndrome and vegetative manifestations is often expressed, in the subsequent accession of stem symptoms is characteristic.
Tool diagnosis of a stroke
Clinical diagnostics allows the neurologist to define the pool in which there was a vascular accident, to localize the center of a cerebral stroke, to define its character (ischemic/hemorrhagic). However clinical differentiation like a stroke in 15-20% of cases is wrong. Tool inspections allow to establish more exact diagnosis. Urgentny carrying out MPT or KT of a brain is optimum. The tomography allows to establish precisely a type of a stroke, to specify localization and the sizes of a hematoma or the center of ischemia, to estimate degree of hypostasis of a brain and shift of its structures, to reveal subarakhnoidalny hemorrhage or break of blood in ventricles, to diagnose a stenosis, occlusion and aneurism of vessels of a brain.
As there is not always a possibility of urgent carrying out neurovisualization, resort to performance of a lyumbalny puncture. Previously carry out Ekho-EG for a definition/exception of shift of median structures. Presence of shift is a contraindication for the lyumbalny puncture menacing in such cases with development of a dislocation syndrome. The puncture can be required when clinical data speak about subarakhnoidalny hemorrhage, and tomographic methods do not find a blood congestion in subweb space. At an ischemic stroke likvor pressure normal or is slightly raised, the research of tserebrospinalny liquid does not reveal essential changes, slight increase of protein and , in some cases — small impurity of blood can be defined. At a hemorrhagic stroke increase in likvorny pressure, bloody color of a likvor, significant increase in concentration of protein is observed; in an initial stage not changed erythrocytes, later — ksantokhromny are defined.
UZDG of ekstrakranialny vessels and transkranialny UZDG give the chance to diagnose and occlusion, to define degree of a stenosis and to estimate collateral blood circulation. The emergency angiography of a brain is necessary for the solution of a question of expediency of thrombolytic therapy, and also for diagnosis of aneurisms. Preference is given to MRT of an angiography or KT of vessels of a brain. For the purpose of identification of the reason of a stroke the ECG, EhoKG, clinical blood test with determination of quantity of platelets, a koagulogramm, biochemical blood test (including blood sugar), the analysis of urine, the analysis of gas composition of blood is carried out.
Treatment of a stroke
The first 3 h from a debut of clinical manifestations are considered as optimum terms of hospitalization and the beginning of therapy. Treatment in the sharpest period is carried out in chambers of intensive therapy of specialized neurologic offices, then the patient is transferred to the block of early rehabilitation. Before establishment of a type of a stroke basic undifferentiated therapy, after statement of the exact diagnosis — specialized treatment, and then long rehabilitation is performed.
Undifferentiated treatment of a stroke includes correction of respiratory function with pulsoksimetrichesky monitoring, normalization HELL and warm activity with daily monitoring of the ECG and HELL (together with the cardiologist), regulation of homeostatic indicators (electrolytes and blood, glucose level), fight against cerebral hypostasis (osmodiuretik, corticosteroids, a hyperventilation, a barbituratny coma, a cerebral hypothermia, decompressive cranial trepanation, external ventrikulyarny drainage).
Symptomatic therapy which can consist of hypothermal means (paracetamol, , diclofenac), antikonvulsant is in parallel performed (diazepam, lorazepam, valproata, tiopentat sodium, geksenat), antiemetic medicines (, ). At psychomotor excitement magnesium sulfate, a haloperidol, barbiturates are shown. Basic therapy of a stroke also includes neurotyre-tread therapy (, piracetam, it is well-cared , glycine) and prevention of complications: aspiration pneumonia, respiratory distress syndrome, decubituses, uroinfektion (cystitis, pyelonephritis), TELA, thrombophlebitis, stressful ulcers.
The differentiated treatment of a stroke corresponds to its pathogenetic mechanisms. At an ischemic stroke the basic is the fastest restoration of a blood-groove of an ischemic zone. Mechanical thrombolytic therapy is for this purpose applied medicamentous and intra arterial by means of the fabric activator of a plazminogen (rt-PA) (ultrasonic destruction of blood clot, aspiration of blood clot under tomographic control). At the proved kardioembolichesky genesis of a stroke antikoagulyantny therapy by heparin or nadropariny is carried out. If it is not shown or it cannot be carried out , then antiagregantny medicines are appointed (acetilsalicylic to - that). Vazoaktivny means are in parallel applied (, ).
In therapy of a hemorrhagic stroke the bleeding stop is priority. Haemo static treatment can be carried out by calcium medicines, Vikasolum, aminokapron to - that, etamsylate, aprotininy. Together with the neurosurgeon the decision on expediency of surgical treatment is made. The choice of surgical tactics depends on localization and the sizes of a hematoma, and also on a condition of the patient. Stereotaksichesky aspiration of a hematoma or its open removal by cranial trepanation is possible.
Rehabilitation is carried out by means of regular courses of nootropic therapy (, , piracetam, a ginkgo of a bilob and so forth), LFK and mechanotherapies, reflexotherapies, elektromiostimulyation, massage, physical therapy. Often patients should restore anew movement skills and to study self-service. If necessary experts in the field of psychiatry and psychologists carry out psychocorrection. Correction of violations of the speech is carried out by the logopedist.
Forecast and prevention of a stroke
The lethal outcome in the 1st month at an ischemic stroke varies from 15 to 25%, at a hemorrhagic stroke — from 40 to 60%. Hypostasis and dislocation of a brain, development of complications act as its main reasons (TELA, an acute heart failure, pneumonia). The greatest regress of neurologic deficiency happens in the first 3 months of a stroke. The worst restoration of movements in a hand, than in a leg is often observed. Extent of restoration of the lost functions depends on a look and weight of a stroke, timeliness and adequacy of rendering medical aid, age, associated diseases. A year later from the stroke moment the probability of further restoration is minimum, through such long period usually only aphasia gives in to regress.
Primary prevention of a stroke is healthy food with the minimum quantity of animal fats and salts, a mobile way of life, the balanced and quiet character allowing to avoid critical stressful situations, lack of addictions. The prevention of both primary, and repeated stroke is promoted by effective treatment of cardiovascular pathology (correction HELL, therapy of IBS, etc.), to a dislipidemiya (reception of statin), reduction of excess body weight. In certain cases as prevention of a stroke surgical interventions — a carotid endarterektomiya, reconstruction of a vertebral artery, formation extra- an anastomoza, expeditious treatment of AVM act.