Stroke

Hippocrates

The first mention of a stroke is the description made by Hippocrates in the 460s BC. e. , which refers to loss of consciousness as a result of a brain disease .

Later, Galen described the symptoms that begin with a sudden loss of consciousness, and designated them with the term ἀποπληξία , “stroke”. Since then, the term "apoplexy" has been firmly and permanently included in medicine, while designating both acute cerebrovascular accident and rapidly developing hemorrhage to other organs ( ovarian apoplexy, adrenal apoplexy , etc.).

William Harvey in 1628 studied how the blood moves in the body, and defined the function of the heart as pumping, describing the process of blood circulation . This knowledge laid the foundation for studying the causes of stroke and the role of blood vessels in this process.

A significant contribution to understanding the pathogenesis of stroke was made by Rudolf Virchow . He proposed the terms thrombosis and embolism . These terms are still key in the diagnosis, treatment and prevention of stroke. Later, he also established that arterial thrombosis is caused not by inflammation, but by fatty degeneration of the vascular wall, and associated it with atherosclerosis ^[7] .

Among all types of stroke, ischemic brain lesions predominate. Although stroke is often referred to as cerebral hemorrhage in everyday speech, in reality hemorrhages — a hemorrhagic form of stroke — account for only 20–25% of cases. Ischemic strokes account for 70–85% of cases, non-traumatic subarachnoid hemorrhages - 5% of cases.

Stroke is currently becoming the main socio-medical problem of neurology .

About 12 million strokes are registered annually in the world, and in Russia more than 450 thousand, that is, every 1.5 minutes, one of the Russians develops this disease. In large megacities of Russia, the number of acute strokes ranges from 100 to 120 per day.

Stroke is currently one of the main causes of disability. 70–80% of survivors of a stroke become disabled, and approximately 20–30% of them need constant care .

In the Russian Federation, a severe number of emergency hospitalized patients (do not exceed 15-30%) and the absence of intensive care wards in the neurological departments of many hospitals contribute to severe disabilities in stroke survivors. The need for active rehabilitation of patients is not sufficiently taken into account (only 15–20% of stroke patients are transferred to rehabilitation departments and centers).

Mortality in patients with strokes largely depends on the treatment conditions in the acute period. An early 30-day mortality rate after a stroke is 35%. In hospitals, mortality is 24%, and in those treated at home - 43% (Vilensky B.S., 1995). About 50% of patients die within a year. Mortality in men is higher than in women.

Strokes are the second most common cause of death in the world in 2011 (more common is coronary heart disease ^{[4] [9]} ). About 6.2 million people die from stroke in a year (about 11% of all deaths) ^[4] . About 17 million people suffered a stroke in 2010. About 33 million people previously suffered a stroke and survived in 2010 ^[10] . Between 1990 and 2010, the number of strokes in developed countries decreased by approximately 10%, and in developing countries increased by 10% ^[10] . The increased risk of death from stroke is observed among residents of South Asia, they account for about 40% of deaths from stroke ^[11] .

In the United States, stroke is the leading cause of disability and in the early 2010s ranks fourth among the leading causes of death ^[12] .

The incidence of stroke increases significantly with age from 30 years of age ^[13] . Old age is the most significant risk factor for stroke. 95% of strokes occur at the age of 45 years and more, 2/3 at the age of more than 65 years ^{[10] [14] [15]} .

There are three main types of stroke: ischemic stroke, intracerebral and subarachnoid hemorrhage ^[3] . Intracerebral and (not in all classifications) non-traumatic subshell hemorrhages belong to hemorrhagic stroke. According to international multicenter studies, the ratio of ischemic and hemorrhagic strokes averages 4: 1–5: 1 (80–85% and 15–20%) ^[16] .

Ischemic Stroke

Ischemic stroke , or cerebral infarction. Most often occurs in patients over 60 years of age who have a history of myocardial infarction , rheumatic heart diseases , impaired heart rhythm and conduction , and diabetes mellitus . A major role in the development of ischemic stroke is played by violations of the rheological properties of blood, the pathology of the main arteries . The development of the disease at night without loss of consciousness is characteristic ^[17] .

Etiopathogenesis

Ischemic stroke most often develops with narrowing or clogging of the arteries that feed the brain . Without getting the oxygen and nutrients they need, brain cells die. Ischemic stroke is divided into atherothrombotic, cardioembolic, hemodynamic, lacunar and stroke according to the type of hemorheological microocclusion ^[18] .

• Aterothrombotic stroke , as a rule, occurs against the background of atherosclerosis of cerebral arteries of large or medium caliber. Atherosclerotic plaque narrows the lumen of the vessel and promotes thrombosis . Possible arterial arterial embolism . This type of stroke develops stepwise, with an increase in symptoms over several hours or days, often debuts in a dream. Often an atherothrombotic stroke is preceded by transient ischemic attacks . The size of the site of ischemic damage varies ^[18] .
• Cardioembolic stroke occurs when the embolism of the brain artery is completely or partially blocked. The most common causes of stroke are cardiogenic embolism with valvular heart defects, recurrent rheumatic and bacterial endocarditis, and other heart lesions, which are accompanied by the formation of parietal thrombi in its cavities. Often an embolic stroke develops as a result of paroxysm of atrial fibrillation. The onset of cardioembolic stroke is usually sudden, in the patient’s wakefulness state. The neurological deficit is most pronounced at the onset of the disease. More often the stroke is localized in the zone of blood supply to the middle cerebral artery, the size of the focus of ischemic damage is medium or large, a hemorrhagic component is characteristic. A history of thromboembolism of other organs is possible ^[18] .
• Hemodynamic stroke is caused by hemodynamic factors - a decrease in blood pressure (physiological, for example during sleep; orthostatic, iatrogenic arterial hypotension , hypovolemia ) or a decrease in cardiac output (due to myocardial ischemia, severe bradycardia , etc.). The onset of hemodynamic stroke can be sudden or step-like, at rest or in the active state of the patient. The sizes of heart attacks are different, localization is usually in the zone of adjacent blood supply (cortical, periventricular, etc.). Hemodynamic strokes occur against the background of the pathology of extra- and / or intracranial arteries (atherosclerosis, septal artery stenosis, abnormalities of the vascular system of the brain) ^[18] .
• Lacunar stroke is caused by damage to small perforating arteries. As a rule, it occurs against the background of high blood pressure, gradually, over several hours. Lacunar strokes are localized in the subcortical structures (subcortical nuclei, inner capsule , white matter of the semi-oval center, base of the bridge), the size of the foci does not exceed 1.5 cm. There are no general cerebral and meningeal symptoms, there is a characteristic focal symptom (purely motor or purely sensitive lacunar syndrome, atactic hemiparesis, dysarthria or monoparesis) ^{[18] [19]} .
• A stroke of the type of hemorheological microocclusion occurs against the background of the absence of any vascular or hematological disease of established etiology. The cause of the stroke is pronounced hemorheological changes, disorders in the hemostatic system and fibrinolysis . Scanty neurological symptoms combined with significant hemorheological disorders are characteristic ^[18] .

Hemorrhagic stroke

In the scientific literature, the terms “hemorrhagic stroke” and “non-traumatic intracerebral hemorrhage” are either used synonymously ^{[20] [21]} or hemorrhagic strokes, along with intracerebral hemorrhage, also include non-traumatic subarachnoid hemorrhage ^{[22] [23] [24]} .

Intracerebral hemorrhage

Intracerebral hemorrhage is the most common type of hemorrhagic stroke, most often occurring between the ages of 45-60. The history of such patients is hypertension , cerebral atherosclerosis, or a combination of these diseases, symptomatic arterial hypertension , blood disease, etc. Precursors of the disease ( fever , increased headache , visual impairment ) are rare. Typically, a stroke develops suddenly, in the daytime, against the background of emotional or physical stress ^[25] .

Etiopathogenesis

The cause of cerebral hemorrhage is most often hypertension (80–85% of cases). Less commonly, hemorrhages are caused by atherosclerosis , blood diseases, inflammatory changes in the cerebral vessels, intoxication , vitamin deficiencies and other causes. Cerebral hemorrhage can occur by diapedesis or as a result of rupture of a vessel. In both cases, the basis for the exit of blood beyond the vascular bed is the functional-dynamic angioedema disorder of the general and especially regional cerebral circulation. The main pathogenetic factor for hemorrhage is arterial hypertension and hypertensive crises , in which spasms or paralysis of cerebral arteries and arterioles occur. Exchange disorders that occur in the focus of ischemia contribute to the disorganization of the walls of blood vessels, which under these conditions become permeable to plasma and red blood cells. So there is hemorrhage by diapedesis. The simultaneous development of spasm of many vascular branches in combination with the penetration of blood into the brain substance can lead to the formation of an extensive focus of hemorrhage, and sometimes multiple hemorrhagic foci. The basis of a hypertensive crisis may be a sharp expansion of the arteries with an increase in cerebral blood flow, due to the failure of its self-regulation at high blood pressure. Under these conditions, the arteries lose their ability to narrow and passively expand. Under increased pressure, the blood fills not only the arteries, but also the capillaries and veins. At the same time, vascular permeability increases, which leads to diapedesis of blood plasma and red blood cells. In the mechanism of the occurrence of diapedetic hemorrhage, a certain value is attached to the violation of the relationship between the coagulation and anticoagulation systems of the blood. In the pathogenesis of vascular rupture, functional-dynamic disorders of vascular tone also play a role. Paralysis of the wall of small cerebral vessels leads to an acute increase in the permeability of the vascular walls and plasmorrhagia ^[26] .

Subarachnoid Hemorrhage

Subarachnoid hemorrhage ( hemorrhage into the subarachnoid space). Most often, hemorrhage occurs between the ages of 30-60. Among the risk factors for developing subarachnoid hemorrhage are smoking, chronic alcoholism and a single use of alcohol in large quantities, arterial hypertension, and overweight ^[27] .

Etiopathogenesis

It can occur spontaneously, usually due to rupture of an arterial aneurysm (according to various sources, from 50% to 85% of cases) or as a result of a traumatic brain injury . Hemorrhages are also possible due to other pathological changes (arteriovenous malformations, spinal cord vascular diseases, tumor hemorrhage) ^[28] . In addition, cocaine addiction , sickle cell anemia (usually in children) are among the causes of NAO; less commonly, taking anticoagulants , coagulation disorders of the blood and pituitary stroke ^[29] . Localization of subarachnoid hemorrhage depends on the place of rupture of the vessel. Most often, it occurs when the vessels of the arterial circle of the large brain rupture on the lower surface of the brain. There is an accumulation of blood on the basal surface of the legs of the brain, bridge, medulla oblongata, temporal lobes. Less often, the focus is localized on the upper lateral surface of the brain; the most intense hemorrhages in these cases can be seen along large furrows ^[26] .

ICD classification

When symptoms of acute cerebrovascular accident occur, emergency assistance must be called immediately to begin treatment as early as possible ^[30] .

Symptoms

A stroke can manifest itself with cerebral and focal neurological symptoms ^[31] .

The cerebral symptoms of a stroke are different. This symptom can occur in the form of impaired consciousness, stupor, drowsiness, or, conversely, excitement, and short-term loss of consciousness for several minutes may also occur. Severe headache may be accompanied by nausea or vomiting. Sometimes dizziness occurs. A person may feel a loss of orientation in time and space. Vegetative symptoms are possible: a feeling of fever, sweating, palpitations, dry mouth ^[31] .

Against the background of cerebral symptoms of a stroke, focal symptoms of brain damage appear. The clinical picture is determined by which part of the brain was damaged due to damage to the blood supply to the vessel ^[31] .

If a part of the brain provides a function of movement, then weakness develops in the arm or leg, up to paralysis . The loss of strength in the limbs may be accompanied by a decrease in their sensitivity, impaired speech, and vision. Such focal symptoms of a stroke are mainly associated with damage to a part of the brain supplied to the carotid artery . Возникают слабость в мышцах ( гемипарез ), нарушения речи и произношения слов, характерно снижение зрения на один глаз и пульсации сонной артерии на шее на стороне поражения. Иногда появляется шаткость походки, потеря равновесия, неукротимая рвота, головокружение, особенно в случаях, когда страдают сосуды, кровоснабжающие зоны мозга, ответственные за координацию движений и чувство положения тела в пространстве. Возникает «пятнистая ишемия» мозжечка, затылочных долей и глубоких структур и ствола мозга. Наблюдаются приступы головокружения в любую сторону, когда предметы вращаются вокруг человека. На этом фоне могут быть зрительные и глазодвигательные нарушения (косоглазие, двоение, снижение полей зрения), шаткость и неустойчивость, ухудшение речи, движений и чувствительности ^[31] .

Факторами риска являются различные клинические, биохимические, поведенческие и другие характеристики, указывающие на повышенную вероятность развития определённого заболевания. Все направления профилактической работы ориентированы на контроль факторов риска, их коррекцию как у конкретных людей, так и в популяции в целом.

• Высокое содержание холестерина и ЛПНП (липопротеины низкой плотности) в крови
• Артериальная гипертония
• Сахарный диабет
• Заболевания сердца (аритмия и тд)
• Малоподвижный образ жизни
• Excess weight
• Age
• Курение
• Drugs
• Alcohol
• Нарушения свертывания крови
• ТИА (транзиторные ишемические атаки) являются существенным предиктором развития как инфаркта мозга , так и инфаркта миокарда
• Апноэ во сне
• Предыдущие случаи инсульта, инфаркта сердца или ТИА
• Болезнь сонных артерий (Асимптомный стеноз сонных артерий ^[32] и тд)
• Заболевание периферических сосудов
• Болезнь Фабри ^[33] .

Многие люди в популяции имеют одновременно несколько факторов риска, каждый из которых может быть выражен умеренно. Существуют такие шкалы, которые позволяют оценить индивидуальный риск развития инсульта (в процентах) на ближайшие 10 лет и сравнить его со среднепопуляционным риском на тот же период. Самая известная — Фрамингемская шкала .

Ученые Гетеборга обнаружили, что мутация rs12204590 вблизи гена FoxF2, по их мнению, ассоциирована с повышенной степенью риска возникновения инсульта ^{[34] [35] [36]} .

Компьютерная томография (КТ) и магнитно-резонансная томография (МРТ) — наиболее важные диагностические исследования при инсульте. КТ в большинстве случаев позволяет чётко отдифференцировать «свежее» кровоизлияние в мозг от других типов инсультов, МРТ предпочтительнее для выявления участков ишемии, оценки распространённости ишемического повреждения и пенумбры. Также с помощью этих исследований можно выявлять первичные и метастатические опухоли, абсцессы мозга и субдуральные гематомы . Если наблюдается ригидность затылочных мышц, но отсутствует отёк диска зрительного нерва, люмбальная пункция в большинстве случаев позволит быстро установить диагноз кровоизлияния в мозг, хотя при этом сохраняется незначительный риск возникновения синдрома «вклинения» мозга. В случаях, когда есть подозрения на эмболию, люмбальная пункция необходима, если предполагается применение антикоагулянтов. Люмбальная пункция имеет также важное значение для диагностики рассеянного склероза и, кроме того, может иметь диагностическое значение при нейроваскулярном сифилисе и абсцессе мозга ^[37] . При недоступности КТ или МРТ необходимо выполнить эхоэнцефалографию и люмбальную пункцию.

Дифференциальная диагностика

На месте

Распознать инсульт возможно на месте, немедля; для этого используются три основных приёма распознавания симптомов инсульта, так называемые « УЗП ». Для этого попросите пострадавшего:

• У — улыбнуться . При инсульте улыбка может быть кривая, уголок губ с одной стороны может быть направлен вниз, а не вверх.
• З — заговорить . Выговорить простое предложение, например: «За окном светит солнце». При инсульте часто (но не всегда!) произношение нарушено.
• П — поднять обе руки. Если руки поднимаются не одинаково — это может быть признаком инсульта.

Дополнительные методы диагностики:

• Попросить пострадавшего высунуть язык. Если язык кривой или неправильной формы и западает на одну или другую сторону, то это тоже признак инсульта.
• Попросить пострадавшего вытянуть руки вперёд ладонями вверх и закрыть глаза. Если одна из них начинает непроизвольно «уезжать» вбок и вниз — это признак инсульта.

Если пострадавший затрудняется выполнить какое-то из этих заданий, необходимо немедленно вызвать скорую помощь и описать симптомы прибывшим на место медикам. Даже если симптомы прекратились ( преходящее нарушение мозгового кровообращения ), тактика должна быть одна — госпитализация по скорой помощи; пожилой возраст, кома не являются противопоказаниями госпитализации.

Есть ещё одно мнемоническое правило диагностики инсульта: У. Д. А. Р. ^[39] :

• У — Улыбка После инсульта улыбка выходит кривая, несимметричная;
• Д — Движение Поднять одновременно вверх обе руки, обе ноги — одна из парных конечностей будет подниматься медленнее и ниже;
• А — Артикуляция Произнести слово «артикуляция» или несколько фраз — после инсульта дикция нарушается, речь звучит заторможено или просто странно;
• Р — Решение Если вы обнаружили нарушения хотя бы в одном из пунктов (по сравнению с нормальным состоянием) — пора принимать решение и звонить в скорую помощь. Необходимо рассказать диспетчеру, какие признаки инсульта (УДАРа) были выявлены, и будет направлена специальная реанимационная бригада.

При инсульте наиболее важно доставить человека в специализированную больницу как можно быстрее, желательно в течение первого часа после обнаружения симптомов. Следует учитывать, что не все больницы, а только ряд специализированных центров приспособлен для оказания правильной современной помощи при инсульте. Поэтому попытки самостоятельно доставить больного в ближайшую больницу при инсульте зачастую неэффективны, и первым действием является звонок в экстренные службы для вызова медицинского транспорта . ^{[40] [41] [42]}

До приезда скорой помощи важно не давать больному есть и пить, поскольку органы глотания могут оказаться парализованными, и тогда пища, попав в дыхательные пути, может вызвать удушье. При первых признаках рвоты голову больного поворачивают на бок, чтобы рвотные массы не попали в дыхательные пути. Больного лучше уложить, подложив под голову и плечи подушки, так чтобы шея и голова образовывали единую линию, и эта линия составляла угол около 30° к горизонтали. Больному следует избегать резких и интенсивных движений. Больному расстегивают тесную мешающую одежду, ослабляют галстук, заботятся о его комфорте.

В случае потери сознания с отсутствующим или агональным дыханием немедленно начинают сердечно-лёгочную реанимацию . Её применение многократно увеличивает шансы больного на выживание. Определение отсутствия пульса больше не является необходимым условием для начала реанимации, достаточно потери сознания и отсутствия ритмичного дыхания. ^[43] Ещё больше увеличивает выживаемость применение портативных дефибрилляторов : будучи в общественном месте (кафе, аэропорт, и т. д.), оказывающим первую помощь необходимо осведомиться у персонала о наличии у них или поблизости дефибриллятора.

Лечение инсульта включает комплекс мероприятий по неотложной помощи и длительный восстановительный период (реабилитацию), проводимый поэтапно ^[44] .

Stroke treatment should be aimed at restoring damaged areas of nerve tissue and protecting nerve cells from the spread of the so-called "vascular catastrophe". The restoration of damaged areas is carried out using a group of special drugs - neuroreparants. And healthy nerve cells protect neuroprotective drugs. Certain drugs successfully combine both of these effects, so they can be used for the treatment of stroke. To restore the lost functions of the body, the patient can be prescribed physiotherapy exercises, massages, speech therapy and other exercises. ^[45]

Emergency care

At the prehospital stage of medical care, the patient’s hemodynamic parameters should be assessed, if there is a pronounced increase in blood pressure (more than 220/120 mm Hg), steps should be taken to reduce it gradually. A rapid decrease in pressure will lead to a deterioration in the patient's condition and loss of cerebral perfusion.

In a stroke, it is most important to take the person to the hospital as quickly as possible, preferably within the first hour after the symptoms are detected. It should be borne in mind that not all hospitals, but only a number of specialized centers, are adapted to provide the right modern care for stroke. Therefore, attempts to independently deliver the patient to the nearest hospital with a stroke are often ineffective. ^[46]

Prior to the arrival of an ambulance, it is important not to give the patient food and drink, since swallowing organs can be paralyzed, and then food, getting into the respiratory tract, can cause choking.

At the first signs of vomiting, the patient's head is turned on its side so that vomit does not enter the respiratory tract. It is better to lay the patient by placing pillows under the head and shoulders, so that the neck and head form a single line, and this line makes an angle of about 30 ° to the horizontal. The patient should avoid abrupt and intense movements. The patient is unbuttoned with tight, interfering clothes, a tie is loosened, and care is taken for his comfort.

Resuscitation activities

Making the correct diagnosis and finding the exact location of the stroke, as well as data on the volume of damaged tissues, allows you to choose the right treatment tactics and avoid more serious consequences. In addition to interviewing and examining the patient, special examinations of both the brain and the heart and blood vessels are necessary.

Resuscitation measures should be aimed at maintaining adequate indicators of hemodynamics and oxygenation.

Pharmacotherapy

Drugs are prescribed according to treatment standards and by decision of the attending physician ^[47] .

Patient Care Features

Pneumonia and pressure sores often join the stroke, which requires constant care, turning from side to side, changing wet clothes, feeding, cleansing the intestines, chest vibration massage .

Post-stroke rehabilitation

In the world practice of rehabilitation treatment after a stroke, a leading place is taken by an interdisciplinary approach, on the basis of which several specialists, mainly a physiotherapist, occupational therapist, speech therapist, lead the treatment (therapy) process .

• Physiotherapist is engaged in the restoration of motor functions.
• An occupational therapist adapts a person after a stroke to everyday life.
• The speech therapist is engaged in the restoration of speech and swallowing (if the patient has aphasia and dysphagia).

The human brain is characterized by a certain natural ability to recover, thanks to the creation of new connections between healthy neurons and the formation of new information chains. A similar property of the brain is called neuroplasticity and can be stimulated during the rehabilitation process. One of the key factors in the effectiveness of any rehabilitation program is the regular execution of a carefully organized, individually selected set of exercises - that is, the general principle of teaching a person a new skill ^[48] .

New methods of rehabilitation include robotic treatments, for example, HAL-therapy , ^[49] which, through repeated targeted repetition of movements, contribute to the activation of the mechanism of neuroplasticity. ^[50]

During rehabilitation in the post-stroke period, various auxiliary methods are used, in particular pharmacological, therapeutic gymnastics, exercises with biological feedback (for various reactions, including EEG , ECG , breathing, movements and supporting reactions ^[51] );

In 2016, Russian scientists announced that they were able to develop a dental apparatus that helps restore the speech of a patient who has had a stroke ^[52] .

In the post-stroke period, the risk of post-stroke depression (PD) is high. It has a negative impact on the rehabilitation process, quality of life, somatic health, and contributes to the manifestation of concomitant mental illnesses (primarily anxiety disorders ). PD significantly worsens survival prognosis. So patients with PD die on average 3.5 times more often within 10 years after a stroke than patients without symptoms of depression. According to statistics, the prevalence of PD is 33%, on average, every third patient with a stroke is exposed to it.

Among the psychic factors that influence the occurrence of post-stroke depression, premobid personality traits and the patient’s attitude to his disease are noted. Depression after a stroke is associated with factors such as speech problems, social isolation , poor functional condition. PD can also have an organic origin and is determined by the localization of brain damage. It is believed that the severity of depression is higher with the localization of stroke in the frontal lobe and basal ganglia of the left hemisphere. Depression may also be a response to drug therapy.

PD is treated with antidepressants , psychostimulants , electroconvulsive therapy (especially with drug intolerance and severe depression that is refractory to treatment), transcranial magnetic stimulation , and cognitive-behavioral therapy . ^[53]

• In Russia, more than 400,000 strokes are registered annually, with a mortality rate of up to 35%.
• The total risk of a second stroke in the first 2 years after the first stroke is from 4 to 14%.
• With an increase in the administration of potassium with food (potatoes, beef, bananas), a significant decrease in blood pressure was noted in individuals with its moderately elevated indices by 11.4 / 5.1 mm Hg. Art.
• In patients who have been receiving diuretics (diuretics) for a long time, hypokalemia is formed (diagnosed with a potassium concentration of less than 3.5 mmol / L) and an increase in the frequency of cardiovascular complications.
• With an increase in daily potassium intake by 10 mmol (for example, when taking potassium and magnesium aspartate ), the risk of stroke with a fatal outcome decreases by 40%. ^[54]

• Transient cerebrovascular accident

• Clinical neurology with the basics of medical and social expertise. SPb .: Medline-Media LLC, 2006.

• Stroke / Medline
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• National Stroke Association, official website
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