Chronic ischemia of cerebral vessels. Chronic cerebral ischemia

Cerebral ischemia is an acute or chronic disorder blood supply to brain tissue.

Forms

There are two forms of cerebral ischemia:

The reasons

More often, chronic cerebral ischemia is caused by atherosclerotic plaques located in the pool vertebral arteries as well as hypertension.

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Chronic ischemia can also be caused by the following conditions:

• pathology of the heart, accompanied by low blood pressure (small cardiac output), cardiac arrhythmias;
• hereditary vascular diseases (angiopathies), malformations and anomalies of their development, compression of blood vessels by various formations, systemic vasculitis (common lesions of inflammatory vessel walls);
• blood diseases associated with a deficiency of hemoglobin and red blood cells;
• diabetes;
• amyloidosis of brain tissue.

Pathogenesis

The main link in the pathogenesis of chronic cerebral ischemia is hypoxia - oxygen deficiency. As a result of prolonged hypoxia, the transport and metabolism of nutrient substrates into the substance of the brain is disrupted, and the processes of energy supply suffer. nerve cells.

At the first stage, the above processes are reversible due to the mobilization of the compensatory forces of the body (increase or decrease blood pressure, expansion or narrowing of the lumen of blood vessels under the influence of hormones and other vasoactive substances). In the future, subcompensation and decompensation of these reactions occur, compensatory possibilities are depleted, and the process becomes irreversible.

All of the above complications are found in post-emectomy arteriography. In addition, bypass may be required in case of injury where the damaged segment is long. This method of treatment can be chosen in cases of acute ischemia with an onset before 12 hours. When choosing fibrinolytic therapy, it is necessary to categorically exclude the presence of aortic dissection as the main cause of acute ischemia.

The advantages of this method are that surgery avoided and opened up to very small vessels that cannot be destroyed by surgical methods. The disadvantages are that it is a more expensive method than surgery, the treatment time is increased by 6-12 hours, there is a high risk of intracerebral bleeding.

Ischemia can initially be subjected to both separate sections white and gray matter, and one or both hemispheres at once - a diffuse lesion.

Every day there is a shutdown and death of hundreds and thousands of neurons, as a result of which the neuronal connections of the affected department with other parts of the hemisphere are disrupted and, after a few months, the first clinical manifestations develop.

Symptoms

Symptoms chronic ischemia of the brain, first of all, depend on the localization and prevalence (single ischemic foci, diffuse ischemia) of the pathological process.

Ischemia medulla oblongata accompanied by gross violations of reflex activity. First of all, this concerns protective reflexes- emetic, coughing, blinking, and the coordination of inhalation and exhalation, swallowing, secretion of gastric juice is also disturbed.

It is similar to local thrombolysis, but in addition to local thrombolysis, the probe in the vicinity of the clot has the ability to aspirate it. The method has the same advantages, disadvantages, contraindications and complications as fibrinolysis. Neruro thromboaspiration is performed without the introduction of fibrinolytic agents.

Therefore, after establishing the diagnosis of acute ischemia, it is necessary to determine the etiology of ischemia: if it is caused by an embolus or thrombosis, this is more likely in patients with lameness before the episode of acute ischemia. In the case of an embolism, an embolectomy is often performed, and in the case of a thrombosis, bypass surgery will be performed most of the time.

When the bridge is damaged, facial expressions and movements are disturbed eyeballs. Damage to the cerebellum is manifested by disorders of coordination of movements varying degrees expressiveness.

Ischemia diencephalon accompanied by a violation of the regulation of metabolism, energy. Ischemia frontal lobes manifested by a violation of active behavior, temporal - hearing, parietal - skin-muscle sensitivity, smell and taste.

With diffuse malnutrition of the left hemisphere, speech disorders occur, motor functions right limbs, with damage to the right hemisphere - a disorder in the assessment of surrounding objects (their size, shape, distance to them, etc.), as well as the movement of the left limbs.

An important feature of chronic cerebral ischemia is the discrepancy between the severity of cognitive impairment (speech, memory, attention) and the number of complaints. The more these functions are impaired, the fewer complaints the patient has.

Stages of encephalopathy

Stage (degree)	Clinical manifestations	Quality of life of patients
1 degree	The clinic is associated with small focal neurological disorders. There may be slowing down and smallness of steps, a decrease in attention, perseverance, uncertain performance of coordination tests, irritability, capriciousness, tearfulness, a tendency to depressive thoughts and statements. At this stage, the level of intelligence already begins to decline.	Doesn't suffer.
2 degree	Symptoms are associated with the progression and spread of ischemic brain damage. At this stage, extrapyramidal disorders are added: violations of muscle tone, movements, hyperkinesis (involuntary muscle twitches) and hypokinesis occur ( a sharp decline movements, up to their absence). There is a lesion of the cranial nerves, characterized primarily by prosoparesis (paralysis of facial muscles) and glossoparesis (of the tongue). Due to the increasing decline in intelligence, despite the deterioration of the condition, the patient begins to complain less, becomes calm and indifferent to the world around him, he ceases to control what is happening and plan his actions.	Signs of social and professional maladjustment begin to appear. The ability to self-service does not suffer.
3 degree	Functional disorders occur pelvic organs- Urinary incontinence, involuntary defecation. Walking and balance are disturbed, in connection with which a person is forced to move with the help of loved ones or look for support in the room so as not to fall. In contrast to stage 2, emotional disinhibition and psychotic disorders. The decrease in memory, speech, thinking is progressing.	Progressive social and professional maladaptation, fading of the ability to self-service.

Diagnostics

Diagnosis of chronic cerebral ischemia is based on a comprehensive study of anamnesis of life, disease and heredity, as well as objective and laboratory and instrumental studies.

When taking anamnesis, it is important to pay attention to whether the patient has coronary disease heart, myocardial infarction, essential and symptomatic (with kidney disease, pheochromocytoma, hyperthyroidism, etc.) arterial hypertension. During an objective examination - on the pulse rate and its symmetry in the upper and lower extremities, the nature pulse wave, arterial pressure, the presence of cardiac and vascular murmurs.

Laboratory diagnostics includes general clinical studies:

• general urine analysis,
• general blood analysis,
• blood biochemistry to determine lipid spectrum and glucose.

To plan instrumental research include:

• EchoCG (ultrasound of the heart, you can detect a thrombus or atherosclerotic plaque that closes the lumen of the chamber of the heart or the mouth of the main vessel),
• ophthalmoscopy.

To assess the level of cerebral blood flow, ultrasound dopplerography, angiography with and without contrast (anomalies in the development of blood vessels, pathological formations can be detected).

Treatment

Treatment of chronic cerebral ischemia is based on the following principles:

Correction of arterial hypertension and hyperlipidemia	The relief of high blood pressure is carried out with the help of drug and non-drug therapy. Non-drug methods are: The most common cause of chronic obstructive arteriopathy is also atherosclerosis. The disease is more common in men, with a prevalence rate of about 5% at age 50. Among the risk factors for the most important illness- smoking, as well as the presence of diabetes. High blood pressure and dyslipidemia also pose a high risk. The disease can persist for a long time at an asymptomatic stage. Later, with the development of significant stenosis, a typical manifestation appears - intermittent claudication, pain that feels like muscle spasms, most often in the calf, which occurs during exercise, walking, and disappears shortly after exercise. The brain may occur initially over long distances, and symptoms may remain stable for long periods of time. Subsequently, worsening the degree of stenosis, the pain occurs as the distance becomes shorter, requiring frequent stops and limitation of the patient's daily activities. a diet with a restriction of protein, salt and other substances that retain fluid in the body; Healing Fitness; rejection bad habits. The main groups of antihypertensive drugs are: diuretics ( ACE inhibitors, thiazide and thiazide-like diuretics, etc.), calcium antagonists, beta-blockers (they have a symptomatic effect), angiotensin II receptor blockers. They are prescribed by the attending physician (therapist, cardiologist). In more complex cases, and pain may occur at rest, then the initial quasi-stationary night, and may be accompanied by trophic disorders - ischemic skin ulcers, gangrene. The disease mainly affects large arteries. When the aorta terminal is involved before branching into two common iliac arteries, talk about Leriche's syndrome. In this case, the symptoms strike as lower limbs, and in men, sexual dysfunction is added. Linking diabetes results in a more diffuse, distal, and usually partial response to treatment.
Correction of hyperglycemia and control of the patient's blood sugar level	First of all, a diet is prescribed with a restriction of animal fats and a decrease in the proportion of total fats to 30% of the daily caloric intake. It is also recommended to increase the intake of complex (“slow”) carbohydrates and reduce the intake of “light” sugars. Vitamins are prescribed (the presence of nicotinic acid in them is especially important). If diet therapy is ineffective, the attending physician prescribes lipid-lowering drugs, such as lovastatin, gemfibrozil, fenofibrate, cholestyramine, and others. Today, you can control the concentration of glucose in the blood daily at home. For such an analysis, special devices are used - glucometers, which do not require special skills and a laboratory. To lower the level of glucose in the blood, a low-carbohydrate diet is prescribed, if necessary, counting of bread units is introduced. If the diet does not help, then hypoglycemic drugs (metformin and its analogues) are added, and in the case of diabetes, insulin therapy.
Therapy of concomitant somatic pathology	Any disease that is observed on the background should be carefully treated under the supervision of a specialist.
Vasoactive treatment	To restore normal cerebral circulation, antiplatelet agents and angioprotectors are used. Antiplatelet agents prevent platelets from sticking together and forming clots. These drugs include heparin, warfarin, chimes, etc. Angioprotectors expand the lumen of blood vessels and increase elasticity vascular wall. These include vinpocetine, nicergoline, cinnarizine, nimodipine, etc. The improvement of cerebral circulation is also facilitated by the rejection of bad habits, primarily smoking. Diagnosis is based on clinical research and imaging studies. Treatment consists of dealing with risk factors, physiotherapy, medical and interventional treatment. Smoking is the main risk factor associated with chronic arteriopathy obliterans, and smoking cessation slows the progression of the disease, critical limb ischemia reduce the occurrence of amputation rate and decreases at rest. Adequate treatment of dyslipidemias, diabetes mellitus and hypertension is recommended. Important recommendation about walking exercises. Walk is indicated until lameness occurs and then stop and resume the exercise. Practically systematize, walking exercises relieve symptoms, prolong the distance traveled and time until lameness occurs. In addition to improving symptoms, walking exercise is promoted as an important measure to reduce the degree of ischemia by stimulating the development of collateral circulation.
Cerebroprotective therapy	The action of cerebroprotectors is aimed at minimizing negative impact hypoxia on brain neurons and preventing the spread of already existing ischemic foci. Most effective drugs are cerebrolysin, gliatilin and cortexin.

Prevention of chronic cerebral ischemia

The main principles of prevention of cerebrovascular accident are:

• proper nutrition,
• exclusion of bad habits,
• regular physical exercises and being outdoors
• treatment of concomitant diseases that can cause the formation of blood clots, atherosclerotic plaques and spasm of the vascular wall.

Food

As mentioned earlier, you should stick to a diet with low content animal fat and easily digestible carbohydrates. To prevent the development of hypertension, it is necessary to limit the daily amount of salt and protein.

Preference should be given frequent appointments food in small portions. Also, it is very important not to drink food with liquid (water, juice, tea) and eat at night. This helps to slow down the digestion process and stimulates the excessive formation of low and very low density lipids that make up atherosclerotic plaques.

Forecast

The prognosis for chronic cerebral ischemia depends on the stage at which the diagnosis was made, as well as the severity of the underlying pathology. When a diagnosis is made at the first stage and early therapy is prescribed, when the body's compensatory capabilities are not yet exhausted, in 90% of cases recovery occurs within a few months and the disease does not leave negative consequences.

The prognosis for chronic cerebral ischemia in newborns is always serious.

Most often, ischemia develops already in utero and is aggravated during childbirth. Immediately after birth, the child's body undergoes a number of powerful changes against the background of changes in hormonal background Therefore, it is very important to immediately diagnose the pathology and start etiotropic and pathogenetic treatment.

If ischemia was detected late and therapy was not carried out on time, the child either dies or remains disabled, since the neuronal connections of the brain responsible for cognitive, motor and other vital functions have already been destroyed. important features organism.

Effects

The consequences of chronic cerebral ischemia are most often represented by disorders of memory, thinking, speech and movements of varying severity.

In the case of newborns, there may be a delay in physical and psychomotor development with the formation of mental retardation.

Chronic ischemia of the brain is a special form of pathology, which is characterized by a lack of blood supply to the tissues of the brain.

A strong decrease in the amount of blood flow to the vessels of the brain causes ischemic damage to neurons. This gradually leads to its focal or diffuse damage.

Violation of circulation provokes the development of microinfarctions. And changes in large arteries cause the formation of extensive cerebral infarctions.

The reasons

Damage to the vascular wall is considered to be the main factor in the development of cerebral ischemia. It can be caused by cardiovascular disease and diabetes.

In addition, chronic cerebral ischemia often occurs for other reasons, namely:

• anomalies in the development of blood vessels great circle blood circulation and arteries (usually they are asymptomatic and progress with changes in the vascular bed);
• processes in venous system(thrombophlebitis and thrombosis);
• diseases of the spine (osteochondrosis, spondylarthrosis, disc herniation);
• amyloidosis internal organs and blood vessels;
• collagenosis, vasculitis and other blood diseases.

Symptoms

The main symptoms of chronic ischemic lesions of the brain correlate with the clinical degrees of the disease. They depend on the diagnosis and treatment of the disease.

The stages of vascular lesions are determined by the manifestations of the disease. They are divided into several stages with special neurological symptoms.

Conventionally, there are three degrees of chronic ischemia syndrome. They may present with various symptoms.

initial stage

The patient complains of noise and heaviness in the head, constant headaches, dizziness, sleep disturbance, increased fatigue and general weakness.

Present:

• decreased attention;
• cognitive activity;
• memory impairment;
• emotional lability syndrome;
• irritability;
• incoordination of movements in the form of a shaky gait.

These symptoms develop and progress over time.

Subcompensation stage

Observed:

• memory loss;
• attention disorder;
• slowing down the activity of mental processes;
• limited ability to plan and control;
• emotional and personality disorders;
• the development of depression and a decrease in self-criticism.

This stage of the disease is characterized by a violation of social and professional adaptation. The ability to self-service is preserved.

Stage of decompensation

Combines a number of signs that also progress:

• the difficulty of initiating movements increases;
• there is a decrease in self-criticism;
• fainting and falling;
• epileptic seizures;
• disinhibition and apathy.

The patient loses the ability to move, while his household and social adaptation, the opportunity to serve themselves at the household level is lost.

Diagnostics

The syndrome of chronic cerebral ischemia is determined by a thorough analysis of all the collected information about the state of the patient's disease.

Diagnosis of chronic cerebral ischemia includes the study of neuropsychological and neurological symptoms. Also, the patient must undergo a cardiological examination, which includes ECG, Holter monitoring and echocardiography.

These examinations serve to establish the underlying cause of the development of chronic cerebral ischemia. Together with laboratory methods researches they give the chance to exclude a somatic pathology.

In order to obtain a complete picture of the disease, studies of the state of the patient's brain tissues are carried out using the following methods:

• CT or MRI of the brain;
• duplex ultrasound scanning;
• ultrasonic dopplerography;
• transcranial dopplerography;
• analysis of rheological and coagulation characteristics of blood.

Treatment

Syndrome of chronic cerebral ischemia of any stage requires immediate treatment.

Therapy is aimed both at preventing the progression of brain disorders, and at preventing the occurrence of exacerbations - crises and small ones.

Even slightest symptoms diseases should alert the patient and the doctor. BUT timely treatment will give a better prognosis.

The treatment of chronic cerebral ischemia is used as a remedy primary prevention ischemic stroke of cerebral vessels. It includes the following steps.

Correction of arterial hypertension

Among them, there are pharmacological and non-pharmacological methods.

Used to prevent pressure buildup medicines, which minimally threaten the blood circulation of the brain vessels when taken regularly.

As non-drug methods, the transition to healthy lifestyle life. The patient should completely give up smoking and alcohol, limit food intake table salt increase the content of fruits in the diet, fermented milk products and vegetables.

Controlling blood sugar levels and correcting hyperglycemia

Used to correct hyperglycemia special diet. Low in calories, vegetable and animal fats, fried and spicy foods.

The diet should be dominated by foods enriched with potassium and rich in iodine. These include dried apricots, prunes, raisins, baked potatoes and seafood.

If the effect is not achieved, apply medical preparations- statins. Long-term use drugs slows down the development of cholesterol plaques, while reducing blood viscosity.

Vasoactive therapy

Treatment of chronic brain disorders is impossible without vasodilators. Positive effect depends on the degree of damage to the cerebral vessels.

It is also necessary to use antithrombotic drugs - acetylsalicylic acid(aspirin), dipyridamole and clopidogrel. These medicines are used continuously for long period time. which can be up to several years.

Appointment of neuroprotectors

Neuroprotection is used to ensure the protection of brain neurons, preventing further cerebral lesion and correction of the consequences of ischemic disease.

Disease prognosis

Syndrome of chronic cerebral ischemia today is a very common disease.

Only A complex approach to therapy this disease can provide timely assistance in case of violations of cerebral functions and pathological changes in cerebral circulation.

Diverse and reasonable approach helps prevent the development of cerebral infarction.

As statistics show, the prognosis of the disease is more favorable in those patients who are constantly monitored by a neurologist.

A timely prescribed treatment regimen with the use of medications, as well as general and surgical methods treatment gives a decrease in the development of cerebral ischemia with partial restoration of neurons.

If the patient progresses accompanying illnesses, they can greatly increase the risk of developing cerebral infarctions.

Complications can cause arterial hypertension, arrhythmia, diabetes mellitus, cardiomyopathy, endocarditis.

An unfavorable prognosis for the health and life of the patient occurs with late visits to the doctor.

Most often, chronic ischemia syndrome can be determined at the stage with severe brain damage. At the same time, the patient has strongly pronounced symptoms of multiple microstrokes and swelling of the brain tissue with mass death of nerve cells. In such cases, the patient often has a severe degree of disability or, with the worst development of the disease, a fatal outcome.

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