Stroke is a neurological syndrome that develops due to acute disruption of normal circulation in blood vessels and tissues to the brain. The clinical picture of this condition is associated with damage to brain tissue, which is a consequence of ischemia or hemorrhage.
At present, this disease is an important social and medical problem. The risk of disability after a stroke is 70-80%.The percentage of mortality in the first month is 35%, and during the year this figure reaches 50%.
Timely provision of qualified hospital care reduces the lethality from 43% to 24%, compared with those who received treatment at home( Vilenskiy BS, 1995).
Table of contents:
- Hemorrhagic stroke
- Ischemic cerebral stroke
- Stroke treatment
- Rehabilitation after a stroke
The most frequent cause of hemorrhagic stroke is arterial hypertension( 50-60%).More rarely, it can occur with atherosclerosis and clotting disorders. At a young age, a hemorrhagic stroke can occur due to rupture of an aneurysm of the cerebral arteries.
A key link in the pathogenesis of a hemorrhagic stroke is the rupture of the vessel or diapedesis( caused by leakage) hemorrhage. Most often it is localized in the large hemispheres or in the region of the subcortical nodes. The hemorrhage focus can also be located in the cerebellum or brainstem.
The development of hemorrhagic stroke is accompanied by the destruction of the brain parenchyma in the lesion and the compression of tissues surrounding the hematoma formed. At the same time, a persistent violation of outflow of blood and cerebrospinal fluid develops. This leads to an increase in intracranial pressure, the development of edema and displacement of the brain.
Clinic of hemorrhagic stroke
Brain symptoms develop very quickly. Their beginning is usually associated with emotional excitement or physical stress. There is a sharp headache, which is perceived as a blow to the nape, there is vomiting, impaired consciousness and coordination of movements. In a few hours these symptoms disappear, and clinical manifestations of the lesion of one or another region of the brain develop:
- In cases of hemorrhage into the cerebral hemisphere, disorders of motor functions or sensitivity are observed. Sometimes there is a paresis of the eye.
- When a hemorrhage into the brain stem, paresis of the limbs is observed, symptoms of lesions of individual nuclei of the cranial nerves arise.
- If the hemorrhage is localized in the cerebellum, then motor disorders develop( decreased muscle tone, ataxia), severe dizziness and multiple vomiting occur.
- Subarachnoid hemorrhage is characterized by a sudden onset, and is accompanied by the development of cerebral and meningeal symptoms.
Ischemic cerebral stroke
The onset of ischemic stroke is associated with impaired blood flow to a limited area of the brain, which is accompanied by the development of tissue necrosis( infarction).Depending on the mechanism of development of ischemia, four subtypes of ischemic stroke are distinguished.
- Atherothrombotic stroke develops when plaque or internal carotid arteries are blocked by atherosclerotic plaques. This subtype of stroke is characterized by a sudden development of paresis or aphasia, which occur more often at night. The appearance of characteristic symptoms is replaced by a short-term improvement in the condition, which is replaced by a more pronounced attack.
- Cardioembolic stroke develops as a consequence of blockage of cerebral vessels by an embolus( thrombus) from the left atrium or ventricle. The cause of embolism may be endocarditis, atherosclerosis, myocardial infarction. The disease develops rapidly. Already in the first hours, clinical symptoms reach maximum severity. There is a sharp loss of consciousness, seizures, blindness, unilateral motor disturbances develop.
- Hemodynamic stroke occurs as a result of stenosis of the main arteries against the background of a sharp drop in blood pressure. At the same time, ischemia of the most remote regions of the brain develops. Clinically, this is manifested by lower or upper paraplegia( less often tetraplegia).
- Lacunar stroke occurs against the background of hypertensive microangiopathy, which develops in the vessels of the brain with arterial hypertension. Disturbance of blood supply in this case is observed in the deep parts of the brain( thalamus, basal ganglia, bridge, cerebellum).The clinical symptoms of lacunar stroke increase within a few hours. Symptomatic symptoms are absent. Depending on the affected area, the following clinical variants of lacunar stroke may occur:
- Motor stroke( hemiparesis);
- Sensitive stroke( hemihypersthesis);
- Sensory motor stroke( hemiparesis and hemi-hypersthesia);
- Ataxic hemiparesis( weakness and impaired coordination in the limb);
- Dysarthria, or "awkward brush".
Treatment of strokes
All patients with strokes should be hospitalized in the first 4-6 hours from the onset of the disease. However, transportation is contraindicated in patients with deep shock or coma, as well as breathing disorders and lung edema development.
Intensive stroke therapy is carried out in the following main areas:
- Maintaining respiration. Includes the release of the respiratory tract and, if necessary, the transfer of the patient to the artificial ventilation of the lungs.
- Maintenance of hemodynamics under the control of cardiac activity. To reduce pressure appoint β-blockers( esmolol, anaprilin) and angiotensin-converting enzyme( enalapril) inhibitors.
- It is expedient to prescribe diuretics( lasix).With a critical reduction in pressure, infusion therapy with colloids in combination with corticosteroids( dexamethasone) and vasopressors( dopamine) begins.
- A sudden increase in temperature to febrile markers can aggravate the course of the disease. To reduce it, resort to external cooling( water-alcohol wiping) or the introduction of non-steroidal anti-inflammatory drugs.
- Correction of arising complications includes:
- In the event of cerebral edema, mannitol or osmotic diuretics are prescribed.
- With the development of hyperglycemia or hypoglycemia, which aggravate the course of stroke, infusion therapy with glucose solutions of the appropriate concentration begins.
- To prevent the development of venous thrombosis in the paralyzed limbs, small doses of heparin( 2-4 thousand units) are prescribed.
Treatment of ischemic stroke associated with obstruction of cerebral vessels begins with the introduction of thrombolytics( alteplase).Direct anticoagulants( heparin) are prescribed in the case of progression of clinical symptoms( especially with stenosis of large arteries), or with a cardioembolic stroke.
To improve the rheological parameters of the blood, hemodilution is performed. For this purpose, intravenous infusion of solutions of rheopolyglucin, albumin and crystalloids is prescribed. In order to improve metabolism, nootropic drugs are prescribed in the brain tissue( gamma-lon, pyracetam, instenon).
Rehabilitation after a stroke
Rehabilitation should include correction of motor and speech disorders. Of great importance in this case is the socio-psychological adaptation of the patient who suffered a stroke.
Prevention of recurrence of stroke includes a number of activities aimed at eliminating risk factors: treatment of hypertension, elimination of hyperlipidemia, compliance with diet. In order to maintain normal circulation, antiplatelet agents( aspirin, clopidogrel) are prescribed.
- Reduce pressure at home