Ischemic heart stroke. They are distinguished by causal factors. Ischemic stroke: treatment

Ischemic stroke is a serious illness in which blood flow to the brain is impaired. The lumen in one of the arteries feeding the brain turns out to be closed. This is usually caused by a blockage by a blood clot, less often a spasm. If there is no blood flow, then the brain tissue suffers from the lack of oxygen and nutrients... The symptoms of ischemic stroke develop almost immediately. Within 5 minutes, cells begin to die if the blood flow has not been restored. The disease can be more or less severe, depending on how much a large artery is blocked and how important the areas of the brain it serves are. Read the article - learn about the causes, symptoms, diagnosis, treatment and consequences. Understand stroke rehabilitation methods. Learn about speech and work recovery, optimal patient nutrition, and treatment of urinary and fecal incontinence.

Ischemic stroke: detailed article

The success of treatment is largely determined by how quickly the patient manages to get medical assistance... Ischemic stroke usually does not cause pain. This is bad rather than good, because patients expect symptoms to go away on their own and do not call a doctor. They waste valuable time as their brain tissue dies. Details about symptoms, diagnosis and emergency care described below. It also provides information about treatment that patients and their loved ones need to know. Are given practical advice for rehabilitation after a stroke in a sanatorium and at home.

Ischemic Stroke: A Medical Dictionary

Watch a video about the causes and treatment of stroke from the famous doctor Elena Malysheva. Take a tour of the institute in Moscow, which provides emergency care for patients with ischemic stroke, and then undergo long-term rehabilitation. Learn about modern methods rehabilitation giving the best results.

Ischemia is a process characterized by a deficiency of oxygen and nutrients. A heart attack is a possible result of this process. Sometimes cerebral ischemia does not last long. The heart attack does not have time to develop, because the blood flow is quickly restored. This is called a transient ischemic attack, in a popular way - a microstroke. In such cases, the symptoms of a stroke quickly subside, usually before the doctor arrives. However, if a transient ischemic attack occurs, the patient must be hospitalized and intensively treated to prevent a "real" ischemic stroke. Read the detailed article ““. Take a microstroke seriously.

Ischemic stroke: causes

The cause of ischemic stroke is usually because the patient did not pay attention to his risk factors and did not take measures to control them. Hypertension and atherosclerosis eventually lead to a stroke, if the patient does not have time to die earlier from cardiovascular disease... It is especially bad if hypertension is aggravated by smoking or diabetes mellitus. Additional risk factors are alcohol abuse, unhealthy eating habits, a sedentary lifestyle, and heart problems such as ventricular (atrial) fibrillation.

If you want to eliminate the causes that can cause blockage of blood circulation in the brain, then study the article "". Find out which good pills from cholesterol and hypertension. To take control of risk factors, you do not have to go on a "starvation" diet and exercise hard labor. To lead healthy image life is easier than it seems.

Typically, an ischemic stroke occurs when one of the arteries supplying the brain is blocked by a blood clot - a blood clot. If the carotid artery is significantly affected by atherosclerosis, then a thrombus can form in one of its problem areas. This is called a thrombotic stroke. Sometimes a blood clot forms in another part of the body and then breaks off and travels with the blood. Eventually, it clogs one of the arteries that carry blood to the brain. Such a stroke is embolic. If a blood clot forms in the heart due to valve problems or atrial fibrillation, then the stroke is cardioembolic.

Read also the detailed article ““. Learn about all possible reasons disasters and how to reliably protect themselves from them.

Symptoms

Symptoms of ischemic stroke are individual, not similar in different patients. What they will be depends on how large an artery has been blocked, and on the importance of the areas of the brain that it serves. As a rule, the signs of ischemic stroke are detected suddenly and abruptly. The most common of them is problems with pronunciation of words, as well as with understanding someone else's speech. All other symptoms are less common. Possible visual impairment, decreased mobility or complete paralysis of the arms, legs, muscle laxity in one half of the face.

Do you see symptoms of a stroke in yourself or someone around you? Call an ambulance urgently! Don't expect it to pass by itself. People who have had a cerebral infarction usually do not complain of pain, but behave strangely - they utter words indistinctly, the body does not obey them, they do not understand someone else's speech poorly. Every minute of delay in treatment increases the patient's chances of being disabled.

In severe ischemic stroke, the patient may faint, but this does not happen often. Usually a person does not experience pain, but only confusion, dizziness. Others may guess that his condition is serious, even if the patient assures that there are no problems. Changes in character, urinary incontinence, difficulty swallowing are symptoms that do not appear immediately, but only after a few hours or days. Read the detailed article ““. Find out how the signs differ in women and men. Learn to distinguish a stroke from other diseases that cause similar symptoms.

Watch a video in which the famous doctor Myasnikov talks about the prevention of ischemic stroke in an elderly person. Find out what symptoms warn you that your risk of cerebral infarction is increased.

Diagnostics

The doctor may suspect a stroke based on the results of a visual examination of the patient, if he cannot pronounce words, his coordination of movements and facial expressions are impaired. But an accurate diagnosis can be made only when doctors do tests and examinations. First of all, you need computed tomography (CT). Therefore, ambulance workers are trying to quickly deliver patients with suspected stroke to a medical facility equipped with a computed tomography machine. This examination allows you to accurately determine whether the patient has had a stroke. And if it really is a stroke, then some kind of ischemic or hemorrhagic.

When examining a patient at the scene, the doctor will ask him and the people around him when the unusual symptoms began and how they were expressed. He will be interested in whether the patient has had a history of heart attack, head trauma, stroke or microstroke (transient ischemic attack) before. The doctor uses a stethoscope to listen to the heart and carotid arteries in the neck. If these arteries are significantly affected by atherosclerosis, then there will be characteristic noises in the stethoscope. The doctor will measure the patient's blood pressure and ask what medications he is taking for hypertension. An ophthalmoscope can detect cholesterol deposits or blood clots in the vessels leading to the eyes.

Analyzes and examinations for the diagnosis of ischemic stroke

It is recommended to first of all do computed tomography- make sure that the stroke is ischemic and not hemorrhagic. Treatment is started immediately afterwards so as not to waste time. The rest of the diagnostic procedures are performed in parallel with the treatment. Read the article ““. Find out in detail how differential diagnosis is performed.

Ischemic stroke: treatment

First read the article ““ to find out how the patient and those around him should act before the doctor arrives. The main treatment for ischemic stroke is carried out in a medical facility. The faster the patient is delivered to the department intensive care, the better the forecast for him. Doctors will take steps to quickly dissolve the blood clot, restore normal blood supply to the brain and stop the death of its tissues. This goal is achieved with the help of drugs. Surgical methods are less commonly used.

The only drug approved for use in dissolving blood clots in ischemic stroke is called tissue plasminogen activator. It is administered intravenously. It is necessary to start treatment with this remedy no later than 3 hours after the stroke. Unfortunately, tissue plasminogen activator has many contraindications and often causes side effects, even as severe as hemorrhagic stroke. Therefore, abroad it is prescribed only to a small number of patients, and even less often in Russian-speaking countries.

Treatment is most effective in the first 1-3 hours from the onset of the disease. You can give the patient aspirin or other pills only after you have made sure that it is an ischemic stroke, and not a hemorrhagic one. The main drug is tissue plasminogen activator. Blood thinners are deadly if you have a brain hemorrhage, which has symptoms similar to a clotted blood clot in the arteries that feed the brain.

First of all, the patient is given a computed tomography. If its results show that the stroke is really ischemic, and not hemorrhagic, immediately give aspirin. This drug reduces the risk of recurring stroke. Unfortunately, it does not dissolve a blood clot that has already blocked the artery. At the scene of the accident, the patient should not be given any aspirin or any other medications until the doctor arrives! In well-equipped clinics there is another way - to bring a small device through the vessels to the site of the blockage of the artery in order to mechanically remove the thrombus. Or, using this device, you can inject tissue plasminogen activator directly into the desired location. Unfortunately, research data refutes the effectiveness of this treatment, so it is not used.

Carotid endarterectomy is surgery to remove atherosclerotic plaques from the carotid arteries. After the operation, the arteries are patched with patches made from artificial material or from the patient's own veins. If the carotid arteries are significantly affected by atherosclerosis, then carotid endarterectomy can reduce the risk of recurrent cerebral infarction. Unfortunately, this operation itself carries a risk, albeit a small one. Instead of scraping out plaque from the carotid arteries, you can widen the lumen in them with angioplasty or stenting. But large-scale studies have shown that alternative options operations carry no less risk.

Study the article "". Read all the details about using tissue plasminogen activator - indications for use, contraindications, possible side effects. Also, understand other medicines that are prescribed for ischemic stroke. These are antiplatelet agents, anticoagulants, pressure pills and statins for cholesterol. Find out what relatives should do while the patient is in the hospital.

Rehabilitation

Rehabilitation is a long-term treatment that is given after the acute period of a stroke has ended. Its goals are to strengthen the strength of the patient, restore or compensate for the lost functions, return the person to a full life, as much as possible. The rehabilitation program for each patient who has suffered a stroke is made individually by the doctors. Its basis is physiotherapy... Exercise as hard as you can, alternating between activities and rest. Passive methods rehabilitation give dubious results, and physical education really helps.

You need to start rehabilitation as early as possible, even in the hospital, preferably in the first days after a stroke. It has been proven that early rehabilitation improves the prognosis. After being discharged from the hospital, it is advisable for the patient to spend some time in a rehabilitation center, and then to be treated at home. In addition to a specialist in physiotherapy exercises, a speech therapist and, possibly, a counseling psychologist should work with a patient who has suffered a stroke. You will probably need an ophthalmologist's consultation. There are also people who are preparing living space for people with disabilities.

Read detailed articles:

• how can the rehabilitation center help;
• how to make life easier at home;
• overcoming depression after a stroke;
• return to work.

Effects

A microstroke or mild ischemic stroke in young people can pass without leaving any consequences at all. But this rarely happens. Only 10-15% of stroke survivors can boast of ideal health. The rest all their lives are struggling with the complications of this disease, which can be more or less severe.

Consequences of ischemic stroke:

• weakness or paralysis in the arms and legs, usually on one side of the body;
• deterioration in skin sensitivity to touch and temperature;
• problems with pronunciation of words, understanding of speech, written text, numbers;
• visual impairment - partial blindness, double vision;
• weakening of memory and ability to concentrate;
• incontinence of urine or feces, constipation;
• depression, anxiety, irritability, emotional instability;
• pain syndrome, especially often in the shoulders;
• intimate problems due to physiological and psychological reasons;
• sleep disorders.

People who have lost mobility due to a stroke face additional risks:

• bedsores;
• deep vein thrombosis;
• pneumonia.

Watch a video on how to care for a bedridden patient who has had a severe stroke.

Hands and feet that do not move for a long time can bend and harden so that they cannot be extended without injury. This is called contracture. To avoid them, you need to perform at least passive exercises for flexion and extension of the joints every few hours. Perhaps, over time, the brain will regain control over them. Read the detailed article ““. Find out how the consequences of an acute disorder differ cerebral circulation that struck the right and left hemispheres.

Forecast

About 20% of people who have an ischemic stroke die in the first hours or later in the hospital. Another 40-50% remain disabled, more or less able to serve themselves. The older the patient, the higher the likelihood of an unfavorable outcome. 10% of people who have a cerebral infarction recover completely. Another 25% have visible signs the fact that they have suffered a serious illness, but can lead a normal life.

The sooner the patient is delivered to the medical facility, the more favorable the prognosis for him. Therefore, at the slightest suspicion of a stroke, immediately call an ambulance. Don't waste time! Do not be afraid to bother doctors in vain, to pay for a false emergency call. The risk of severe consequences of ischemic or hemorrhagic stroke is so high that it outweighs all the listed risks.

The prognosis after ischemic stroke depends on the patient's desire and ability to engage in physiotherapy exercises, as well as work on the restoration of speech. Many people manage to fully recover as if they never had a stroke. To do this, you need to diligently perform rehabilitation exercises. For patients who rely on quack funds, the prognosis is rather poor.

Above are data from English-language sources. In Russian-speaking countries, the prognosis for patients is less favorable, because Ambulance travels slowly, ICUs are poorly equipped, and staff rarely receive training in stroke management. V Western countries allocate a lot of money for long-term rehabilitation of patients. In Russian-speaking countries, the affected person and his family receive little help from the state and the people around him.

While the patient, who has had a cerebral vascular accident, is in the hospital, doctors in the first few days are afraid to make predictions. It is only later that it becomes clear how the situation is developing. People who have become paralyzed on one side of the body may hope that physical therapy will help them to partially restore the lost functions. This goal is achieved by 50% of patients - those who exercise diligently. A paralyzed arm is usually more difficult to recover than a leg. Physical disabilities that have not disappeared 12 months after the stroke are likely to remain forever.

Acute disturbance of cerebral circulation due to blockage of cerebral blood vessels will quickly lead to dysfunction of the brain. If this condition continues for more than a day, then they say that the patient has had an ischemic stroke or cerebral infarction. This pathological situation most often develops in patients over 50 years old with such chronic diseases, how arterial hypertension, atherosclerotic disease and decompensated diabetes mellitus. In recent years, there has been a clear tendency to rejuvenate the patient population.

The prevalence of pathology is quite high in all countries and ranges from 2 to 7 primary cases per year per thousand inhabitants. In Russia, ischemic cerebral stroke ranks second among the causes of total mortality after ischemic disease heart and first place in the structure of primary disability in patients of working age. The urgency of the problem dictates the need to educate the population on this issue.

Etiology and pathogenesis

The human brain is very sensitive to a lack of oxygen, therefore, the cessation of blood supply to certain parts of it leads to rapid death. nerve cells and the development of neurological disorders. This can happen when a vessel delivering blood is ruptured, as well as when its lumen is completely or partially closed.

The classification is based on this: stroke hemorrhagic and ischemic cerebral infarction... In the first case, we are talking about intracranial hemorrhage. In the second case, a cerebral infarction occurs - this is the most common reason acute cerebral vascular accident, especially in the elderly. This happens when the lumen is completely or almost completely blocked. blood vessel feeding one or another part of the brain, as a result, its blood supply stops or significantly deteriorates.

The pathogenesis of ischemic stroke is similar to. Most often, it is associated with the development of atherosclerotic growths in the mouths of the carotid arteries - these vessels supply blood to all vital structures of the brain. The uneven inner surface of such an artery and the slowed down blood flow in it create all the conditions for thrombosis - the formation of a blood clot inside the vessel. Another cause of ischemic stroke can be embolism - a blood clot or other formation formed in any place of the circulatory system, for example, in the cavities of the heart, into the cerebral artery. In addition to thrombosis and embolism, cerebral infarction is caused by such reasons as:

• a sharp spasm of the cerebral arteries is a rare phenomenon that occurs a few days after subarachnoid hemorrhage;
• stenosis (narrowing) of blood vessels due to a sudden drop in pressure in the peripheral arteries (shock, collapse), the situation is aggravated in the presence of atherosclerotic changes in the cerebral basin.

Practical medicine shares concepts, for example, what is an ischemic type of stroke and short-term forms of cerebrovascular accident, which last less than a day and end with the complete disappearance of suddenly arising impaired functions.

Transient disorders of cerebral circulation are called transient ischemic attacks, with frequent recurrence, they can be precursors of cerebral infarction.

V foreign countries there is the concept of a minor stroke. This means a violation of the blood circulation in the brain, in which all neurological symptoms disappear gradually over a period from a day to three weeks maximum. It is considered as one of the types of ischemic stroke with complete restoration of lost functions or as a reversible neurological deficit of ischemic origin. Sometimes this form is mistaken for a transient attack, which can affect the treatment of stroke.

The main types and their characteristics

Depending on the pathogenesis, there are several types of cerebral infarction, each has its own characteristics:

1. Atherothrombotic form of stroke - develops against the background of atherosclerosis lesions of the cerebral arteries of large and medium diameter. Thrombosis often occurs in altered vessels, in addition, there is always a risk of embolism from other arteries. This type of ischemic stroke is characterized by a gradual stepwise development with a debut during a night's rest and an increase in symptoms over several hours / days. Sometimes a transient ischemic attack is a precursor.
2. Cardioembolic variant - may occur in individuals with various diseases the heart against the background of the formation of blood clots in its chambers (valvular defects, atrial fibrillation, rheumatism, endocarditis, prolapse of the MC, etc.). The first signs of an ischemic stroke of this type appear suddenly during the active actions of the patient. The lesion is medium or large size... In the history of these patients, thromboembolism of other localizations.
3. Cerebral infarction of hemodynamic origin - usually occurs with a sharp decrease in blood pressure (shock, blood loss) and a decrease in cardiac output during myocardial ischemia. The onset of cerebral infarction symptoms can be sudden or gradual, during rest or physical work. Most often it develops as a complication of vascular anomalies, atherosclerosis, cerebral artery stenosis.
4. Lacunar type of ischemic stroke - only specialists know this. The development of pathology is associated with damage to small arteries. Begins cerebral infarction gradually, foci of ischemia are localized in areas located under the cerebral cortex. Characterized by the absence of cerebral symptoms, a course of the type of small stroke.
5. Stroke against the background of hemorheological microocclusion - this pathology is associated with a violation of the blood coagulation system (hemostasis) and the process of dissolution of intravascular clots (fibrinolysis). A pronounced dissociation between the symptoms of ischemic stroke and hemorheological disorders is characteristic. This means that with a small focus of brain damage and minor neurological disorders, there is a serious intravascular aggregation of blood corpuscles. The way it proceeds and cerebral infarction, resembles a minor stroke.

There are other classifications of ischemic stroke that are necessary for the practice of specialists:

• By localization of the focus - the area of ​​blood supply to various arteries, including the internal carotid, vertebral, cerebral branches.
• The severity of the stroke is mild (neurological symptoms disappear in 20 days, as in the minor form ischemic cerebral infarction), medium (focal symptoms are more pronounced than cerebral symptoms, there is no disturbance of consciousness), severe (cerebral symptoms prevail, depressed consciousness).

Clinical manifestations

Dysfunctions of the brain in acute disorder of cerebral circulation consist of two groups of symptoms:

1. General cerebral signs - observed in severe cerebral infarctions in the form of impaired consciousness such as stunnedness, drowsiness, agitated state, complete loss is rare. Headache always present, as well as nausea, vomiting, dizziness, pain in eyeballs... Less commonly, there may be seizures, vegetative disorders - excessive sweating, dry mouth, feeling hot, etc.
2. Focal neurology in ischemic stroke is an individual set of symptoms for each patient, which depends on which part of the brain is specifically affected, how extensive the lesion is and whether there are accompanying aggravating circumstances. Half of the body, opposite to the affected hemisphere of the brain, always suffers. Focal neurological symptoms include:

• complete violation of movements in the limbs (paralysis) or in partial volume (paresis);
• paralysis and paresis facial nerves(drooping of the corner of the mouth or eye, alignment of the nasolabial fold on one side, “sail” cheek, asymmetrical smile);
• visual disturbances (dark or luminous points before the eyes, decreased visual acuity, loss of fields, diplopia, etc., up to blindness);
• unsteadiness and instability of body position, uncertainty of gait;
• loss of speech in varying degrees, violations of oral and written skills;
• impossibility or difficulty in performing targeted actions;
• loss of temporal and spatial orientation, memory, etc.

The most severe condition is observed in patients who have undergone extensive ischemic stroke with several foci of brain damage, for example, as a result of blockage of the left and right carotid arteries. At the same time, a person is in an unconscious state, he has paralysis of the limbs on the opposite side of the affected cerebral hemisphere. If the patient does not receive correct treatment stroke in the first hours, then there is a high probability of death or the development of serious complications. NS the consequence of such a cerebral infarction will be that the person will become in need of the constant implementation of outside care. Restoring movements in the limbs is possible only in a very small percentage of cases. The main therapeutic measures are used to prevent recurrence of ischemic stroke.

Survey

It should be noted that suspicion of acute violation cerebral circulation is the reason for the immediate hospitalization of the patient in the neurological department of the hospital.

What is it - a diagnosis of a heart attack brain or other similar disease, and the establishment of its pathogenetic variety should be carried out as soon as possible after the patient is admitted to the hospital.

Clinical diagnosis of ischemic stroke is based on the following criteria:

• the patient has a history of indications of repeated transient attacks;
• angina pectoris or signs of ischemic processes in the lower extremities were previously identified;
• have heart disease (atrial fibrillation, rheumatic valvular disease, bacterial endocarditis, coronary artery disease, etc.);
• the debut of the disease during a night's sleep, after taking a bath with hot water, physical work or during (after) an attack of arrhythmia or angina pectoris, after blood loss, etc.;
• progression pathological process gradual or stepwise;
• patient age category 50+;
• the predominance of focal signs over cerebral neurological manifestations.

In the emergency room of the hospital, the general and neurological status of the patient is assessed, general clinical blood and urine tests are performed, additional laboratory tests are prescribed at the discretion of the doctor. A maximum of 40 minutes after admission to the emergency room of the hospital, the patient should be transferred to a specialized department, and treatment of a stroke should be started.

Among instrumental methods the main surveys are:

1. Recording an electrocardiogram in dynamics.
2. CT scan of the brain - to exclude possible intracerebral hemorrhage.
3. MRI in T1 and T2 modes - to assess the extent of the lesion, to confirm the severity of the process and differentiate the diagnosis.
4. Doppler ultrasound examination of the vessels located inside and outside the skull.

Additionally, in each specific case, other types of research can be assigned:

• Ultrasound of the heart;
• ECG monitoring per day according to Holter;
• echoencephalography;
• Ultrasound of the kidneys, organs abdominal cavity etc. according to indications.

Principles of therapy

Treatment of ischemic stroke in the acute period is carried out mainly conservative methods... The basis is thrombolytic (thrombus-dissolving) intravenous therapy. Used by special drug protein nature, converting plasminogen into its active form (enzyme plasmin), which has fibrinolytic activity. It effectively dissolves blood clots in the cerebral vessel when applied early (within the first 3-4 hours from the onset of the disease) and can significantly alleviate the patient's condition.

This method of therapy is carried out only after agreement with the patient or his close relatives, while the diagnosis on CT must be confirmed and the exact time of the onset of the disease is known. Patients with a severe form ischemic infarction unconscious, thrombolysis is contraindicated.

How to treat ischemic stroke if thrombolysis is impossible or after its end - no later than two days after the onset of the disease, antiplatelet drugs are prescribed that prevent the formation of dense blood clots... For example, Acetylsalicylic acid, Dipyridamole MB or Clopidogrel. Subsequently, for at least six months, Warfarin or drugs based on Aspirin are prescribed inside. This therapy is especially indicated for patients suffering from angina attacks or myocardial infarction.

Treatment of ischemic stroke after hospitalization is carried out under the supervision of a neurologist. The goal is to prevent relapses and complications. Drug therapy should be carried out in conjunction with the means of psychotherapeutic support and adaptation of a person to new living conditions, including the restoration of lost functions (exercise therapy, massage, physiotherapy, etc.).

A new direction in the use of stem cells to restore lost neurons gives hope; work in this vein is being actively carried out in a number of countries, including ours. Primary prevention ischemic stroke consists in actively identifying risk groups and taking measures in accordance with the existing pathology, for example:

• fight against extra pounds body weight;
• diabetes and hypertension treatment;
• taking antithrombotic drugs for atrial fibrillation, aspirin and statins in patients with coronary artery disease, etc.

The prognosis depends on the volume and localization of the ischemic focus in the brain, the age and characteristics of the patient's body.