How is rehabilitation after left-sided ischemic stroke going? What is ischemic stroke?

Ischemic cerebral stroke is an acute violation of the blood supply to the brain resulting from the interruption or obstruction of blood supply. The disease is accompanied by damage to the brain tissue, disruption of its work. Acute circulatory disorders of the brain by ischemic type account for 80% of all strokes.

Stroke poses a serious threat to able-bodied and elderly people, leads to prolonged hospitalization, severe disability, high financial costs of the state, deterioration in the quality of life of affected people and their family members.

Stroke is a disease of the century

Stroke affects about 6 million people in the world every year, about 4 million of them die, half of them remain disabled. The number of patients in Russia is at least 450 thousand people per year. Worst of all, the incidence is increasing and the age of sick people is getting younger.

Types

There are 5 types of ischemic stroke, depending on the mechanism of its origin, that is, pathogenesis:

• Thrombotic. The cause (or etiology) is atherosclerosis of the large and medium arteries of the brain. Pathogenesis: an atherosclerotic plaque narrows the lumen of the vessel, then, after exposure to certain factors, a complication of atherosclerosis occurs: the plaque ulcerates, platelets begin to settle on it, forming a thrombus, which blocks the inner space of the vessel. The pathogenesis of thrombotic stroke explains a slow, gradual increase in neurological symptoms, sometimes the disease can develop within 2-3 hours in several acute episodes.

Thrombotic stroke usually develops against the background of atherosclerosis

• Embolic. Etiology - blockage of a vessel by a thrombus coming from internal organs. Pathogenesis: a thrombus forms in other organs, after which it breaks off and enters the cerebral vessel with the blood flow. Therefore, the course of ischemia is acute, rapid, the lesion focus is impressive in size. The most common source of blood clots is the heart, cardioembolic stroke develops with myocardial infarction, cardiac arrhythmias, artificial valves, endocarditis; less often, atherosclerotic plaques in large major vessels are the source of blood clots.

A common cause of cerebral vessel obstruction is a cardiogenic embolus.

• Hemodynamic. At the heart of the pathogenesis is a violation of the movement of blood through the vessels. Etiology - low blood pressure, this phenomenon can be observed with a slow heart rate, ischemia of the heart muscle, during sleep, prolonged standing in an upright position. The onset of symptoms can be rapid or slow, and the disease occurs both in calmness and during wakefulness.
• Lacunar (the size of the focus does not exceed 1.5 cm). Etiology - lesion of small arteries in hypertension, diabetes mellitus. The pathogenesis is simple - after a cerebral infarction, small cavities-lacunae appear in its depths, a thickening of the vascular wall occurs or the lumen of an artery is blocked due to compression. This explains the peculiarity of the course - only focal symptoms develop, there are no signs of general cerebral disorders. Lacunar stroke is more often recorded in the cerebellum, the white matter of the brain.

Lacunar stroke, as a rule, is a consequence of arterial hypertension

• Rheological. Etiology is a blood clotting disorder that is not associated with any diseases of the blood and vascular system. Pathogenesis - the blood becomes thick and viscous, this condition prevents it from entering the smallest vessels of the brain. During the course of the disease, neurological disorders come to the fore, as well as problems associated with blood clotting disorders.

The most common causes of ischemic stroke are thrombosis and embolism.

Types of stroke according to the rate of increase in neurological symptoms

Depending on the rate of formation and the duration of the persistence of symptoms, 4 types are distinguished:

• Microstroke or transient ischemic attack, transient cerebral ischemia. The disease is characterized by mild severity, all symptoms disappear without a trace within 1 day.
• Small stroke. All symptoms persist for more than 24 hours but less than 21 days.
• Progressive ischemic stroke. Differs in the gradual development of the main neurological symptoms - over several hours or days, sometimes up to a week. After that, the health of the sick person is either gradually restored, or neurological abnormalities persist.
• Completed stroke. Symptoms persist for more than 3 weeks. A cerebral infarction usually develops, after which severe physical and mental health problems sometimes persist. With extensive stroke, the prognosis is poor.

Clinic

The main symptoms are:

• Movement disorders of varying severity. Disorders of the cerebellum: lack of coordination, decreased muscle tone.
• Violation of the pronunciation of one's own and the perception of someone else's speech.
• Visual impairment.
• Sensitive disorders.
• Dizziness, headache.
• Violation of the processes of memorization, perception, cognition. The severity depends on the size of the lesion.

The clinic depends on the cause of the disease, the size and location of the lesion. It is worth distinguishing between lacunar infarction, lesions of the carotid, anterior, middle, posterior and villous cerebral arteries, special attention is paid to ischemia of the vertebro-basilar basin.

Ischemic stroke of the vertebrobasilar basin (VBB)

The vertebral arteries merge at the base of the brain into the basilar artery

Two vertebral arteries, merging, form one basilar, that is, the main one. With vascular insufficiency of these arteries, two important parts of the brain suffer at once - the trunk and the cerebellum. The cerebellum is responsible for the coordination, balance and tone of the extensor muscles. The dysfunction of the cerebellum can be called "cerebellar syndrome". The brain stem contains 12 cranial nerve nuclei, which are responsible for swallowing, eye movement, chewing, and balance. After a stroke in the brain stem, these functions can be impaired to varying degrees. In ischemic strokes, focal disorders of the cerebellar function in combination with symptoms of brain stem damage predominate.

Symptoms of acute vascular insufficiency of the vertebral arteries: as a result of damage to the cerebellum, imbalance and coordination of movements occur, with damage to the cerebellum, muscle tone decreases, as a result of damage to the cerebellum, there is a violation of the coordination of muscle movements. If the trunk is damaged, oculomotor disorders, facial nerve palsy, paresis of the extremities (alternating syndrome), chaotic movement of the eyeballs, combined with nausea, vomiting and dizziness, appear, a person has poor hearing. The trunk also regulates the reflexes of chewing and swallowing.

With simultaneous damage to the basilar or both vertebral arteries, the course of the disease worsens, there is paralysis of both arms and legs, coma.

The course of TIA with damage to the intracranial part of the vertebral artery and posterior cerebellar artery is not severe, manifested by nystagmus, dizziness with vomiting and nausea, impaired facial sensitivity, changes in the perception of pain and temperature.

Diagnostics

Treatment tactics are determined by the type of stroke

To select a treatment regimen, it is very important to establish the form of an acute vascular disorder, because medical tactics for hemorrhages and ischemia have serious differences.

Diagnosis of cerebrovascular accident by ischemic type begins with a medical examination, the main symptoms of the disease and the existing risk factors are taken into account. The doctor listens to the heart, lungs, measures the pressure on both hands and compares the indicators. To clarify neurological disorders, to determine the severity, it is imperative to undergo an examination by a neurologist.

For an emergency diagnosis and clarification of the cause of the disease, an ultrasound examination of the vascular bed of the brain, an electroencephalogram is performed, angiography allows you to more accurately see changes in the vascular system of the brain - contrast is injected into the vessels and an X-ray is taken, often you have to do MRI and CT of the brain. In addition, the diagnosis of ischemic stroke should include a finger and vein blood test, a coagulation test, and a general urinalysis.

Prophylaxis

Prevention of ischemic cerebral circulation disorders is aimed at eliminating risk factors and treating concomitant diseases. Primary prevention is aimed at preventing the first attack in life, secondary prevention of recurrent stroke.

Prevention of ONMK

The International Health Organization has established a list of preventive measures:

• Refusal from cigarettes. After quitting active and passive smoking, the risk of stroke is reduced significantly even in older people who have smoked their entire adult life.
• Avoiding alcohol. It is not recommended to drink alcohol even in moderation, because each person has his own individual concept of moderation. It is completely necessary to give up alcohol for people who have already suffered an acute disturbance of cerebral blood supply in their lives.
• Physical activity. Regular physical activity at least 4 times a week will have a positive effect on weight, the state of the cardiovascular system, and the fatty composition of a sick person's blood.
• Diet. The diet consists in moderate consumption of fats, it is recommended to replace animal fats with vegetable fats, eat fewer simple carbohydrates, eat more fiber, pectins, vegetables, fruits and fish.
• Reducing excess body weight. Weight loss should be achieved by reducing the calorie content of food, establishing 5-6 meals a day, increasing physical activity.
• Normalization of blood pressure is the most effective prevention of ischemic stroke. With a healthy blood pressure, the risk of developing a primary and repeated stroke is reduced, and the work of the heart is normalized.
• It is necessary to adjust the blood sugar level in diabetes mellitus.
• It is necessary to restore the work of the heart.
• Women are advised to stop using contraceptives that contain large amounts of estrogen.
• Drug prophylaxis. Secondary prevention of ischemic stroke must necessarily contain antiplatelet and anticoagulant drugs - Aspirin, Clopidogrel, Dipiradamol, Warfarin.

Secondary prevention medication

Observing the listed preventive measures for a long time, you can reduce the risk of developing any diseases of the cardiovascular system.

75% of strokes are primary, which means that by observing preventive measures, it is possible to reduce the overall incidence of stroke.

Forecast

The chances of a favorable outcome for each person are different and are determined by the size and location of the lesion. Patients die after the development of cerebral edema, displacement of the internal structures of the brain. The chances of surviving are 75–85% of patients by the end of the first year, 50% after 5 years, and only 25% after 10 years. Mortality is higher in thrombotic and cardioembolic strokes, and very low in lacunar type. Low survival rate in elderly people, hypertensive patients, smokers and drinkers of alcohol, people after a heart attack, with arrhythmias. The chances of a good recovery decrease rapidly if neurologic symptoms persist for more than 30 days.

In 70% of the surviving people, disability persists for a month, after which the person returns to his usual life, 15-30% of patients after a stroke remain stable disabled, the same number of people have every chance of developing a second stroke.

Patients who have had a microstroke or a minor stroke have a chance to leave for work early. People with extensive strokes may return to their previous place of work after a long recovery period or not leave at all. Some of them can return to their original place, but for an easier job.

With timely assistance, properly selected treatment and rehabilitation, it is possible to improve the patient's quality of life and restore the ability to work.

Stroke is not a hereditary, chromosomal and inevitable disease. For the most part, a stroke is the result of chronic human laziness, overeating, smoking, alcoholism and irresponsibility to doctor's prescriptions. Enjoy life - run in the morning, go to the gym, eat natural light food, devote more time to your children and grandchildren, spend the holidays with delicious non-alcoholic cocktails and you will not have to learn about the causes and statistics of stroke.

Ischemic stroke in the vertebrobasilar basin occurs due to impaired blood flow in the arteries. What causes this disease? How it develops, manifests itself, is diagnosed and treated, as well as whether there is prevention, we will consider in this article.

The vertebrobasilar basin includes the basilar and vertebral arteries. Their task is to supply blood to the vital parts of the brain. Ischemia, which has arisen for vascular or external reasons, negatively affects the work of these departments.

Chronic circulatory disorders often result in a high-fatality stroke. It is important for people at risk to monitor their well-being and, at the first symptoms of the disease, immediately seek specialized help.

What is vertebrobasilar insufficiency?

Vertebrobasilar insufficiency is a pathological condition that develops when blood flow in the main or vertebral arteries is disturbed. At the same time, a lack of oxygen and nutrients leads to a deterioration in the work of a rather extensive area of ​​the brain.

The vertebrobasilar basin supplies approximately one third of the central nervous system, namely:

• cervical spinal cord;
• medulla;
• bridge;
• hypothalamus;
• the main lobes of the brain.

Ischemic damage to vital centers located in these parts of the central nervous system is often fatal.

Reasons, or Why does this type of brainstroke occur?

Ischemic stroke in the vertebrobasilar basin occurs for two groups of reasons:

• vascular;
• extravascular.

The first group occurs in the vast majority of patients, the second accounts for no more than 10% of cases.

Among the vascular factors, the most significant are narrowing of the lumen or blockage of the arteries due to atherosclerotic changes in the wall. More often, the pathological process is localized at the level of the subclavian artery.

Developmental abnormalities are another common vascular cause:

• hypoplasia, in which the lumen of the arteries is significantly reduced;
• pathological vascular tortuosity;
• discharge from the main arteries.

From the extravascular group of reasons - a stroke in the vertebrobasilar basin often occurs due to embolism and compression of the arteries from the outside.

Symptoms of vertebrobasilar insufficiency of VBI

The clinical picture of ischemic vertebral-basilar insufficiency is polysymptomatic. It depends on the height and degree of arterial damage, the development of collaterals, the level of blood pressure, and other factors. As a rule, at the onset of the disease, the symptoms are unstable and bother the patient at least 1 time per week.

The initial manifestations of circulatory failure include:

1. Dizziness. This symptom occurs due to a deterioration in blood flow in the parts of the vestibular system. Dizziness can be combined with nausea, vomiting, which indicates severe damage to the brain area. This symptom occurs suddenly, with an attack, after turning the head or changing the position of the body. Dizziness lasts several minutes.
2. Pain syndrome. The pain is localized in the occipital region, sometimes with a transition to the neck, temples.
3. Instability when moving. This symptom indicates the involvement of the cerebellum in the process. The patient shows unsteadiness when walking, he is unable to stand confidently, to keep the position of the body.
4. Visual disturbances. Most often, the patient complains of flashing flies, the appearance of hallucinations, and a decrease in the field of vision. Such symptoms are aggravated by bending, abrupt rise from a horizontal position, head movements.
5. Hearing disorders. These are symptoms of impaired blood supply to the brain stem. A common manifestation is tinnitus. It has different tonality and intensity, can be combined with a decrease or short-term hearing loss.
6. Memory impairment. The defeat of the sections of the temporal lobe is accompanied by a decrease in the ability to memorize new information.

The appearance of the first symptoms of ischemic vertebrobasilar insufficiency should be a signal for immediate medical attention due to the high likelihood of developing a stroke. According to statistics, it reaches 30-50% of the total number of patients with chronic cerebral ischemia.

Treatment of vertebrobasilar insufficiency

The therapy is carried out medically. Patients receive:

• Antihypertensive medications that help normalize blood pressure readings.
• Diuretics to reduce cerebral edema.
• Anticoagulants, antiplatelet agents. They are used to treat patients with a diagnosed ischemic variant of vertebro-basilar stroke. They help to maintain the rheological parameters of the blood at an acceptable level, preventing further thrombus formation.
• Neuroprotective agents. They help protect sensitive nervous tissue from hypoxia, which has a positive effect on its viability.

In any case, the approach to treatment depends on the severity of the patient's condition and is determined individually. The main task is to quickly transport a patient with suspected ischemic vertebral-basilar stroke to a specialized neurological department.

Prophylaxis

There is no specific prophylaxis for vertebrobasilar insufficiency. All activities are aimed at correcting a person's lifestyle. Experts recommend:

• Increased physical activity. For the purpose of prevention, outdoor walks and swimming are ideal. Physical exercises in the gym should be dosed, without excessive exertion.
• Diet change. Another direction in the prevention of vascular pathology. Nutritionists advise limiting salt, completely abandoning alcoholic beverages, and reducing the amount of animal fats in food. The diet should be dominated by fresh vegetables and fruits, dairy products.
• To give up smoking. Nicotine causes a spastic decrease in the lumen of blood vessels, which impairs blood flow in all organs, including the brain.
• Taking aspirin. The constant intake of small doses of acetylsalicylic acid is the prevention of thrombus formation. It is recommended for patients over 50 years of age.
• Constant monitoring of blood pressure levels.
• Regular preventive examination by specialists. The optimal frequency is once a year.
• Control of blood biochemical parameters.

PACIFIC STATE MEDICAL UNIVERSITY

Department of Psychiatry and Neurology

Head Department: Doctor of Medical Sciences, Professor Ulyanov I.G.

Lecturer: Doctor of Medical Sciences, Professor Gulyaeva S.E.

DISEASE HISTORY

Clinical diagnosis

Concomitant: Hypertension III degree

Completed: student 402 gr. l / f

Barabash A.S.

Vladivostok

PASSPORT SECTION

Age: 48 years old

Nationality Russian

marital status: Not maried

Profession: driver

Place of residence:

Date of admission to the clinic: 03/29/2015

COMPLAINTS

For weakness in the left hand and its numbness, as well as for speech impairment.

ANAMNESlS MORBI:

In the evening of March 29, I began to feel numbness in my left hand, it became weak. Then he called a friend and noted that he could not clearly express himself, his speech was broken. Then he called the ambulance team, which took him to the hospital of the KGBUZ VKB No. 1. The ambulance doctor stated that the blood pressure was 260/120 mm. rt. st

ANAMNESIS VITAE:

Denies viral hepatitis, tuberculosis, sexually transmitted diseases and AIDS. There were no injuries, operations or TBI. Allergic history is not burdened. Increase in blood pressure from 35 years. Material and living conditions at different periods of life are satisfactory. Hereditary history: the patient's mother had hypertension, obesity. Bad habits: does not smoke. He denies alcohol abuse and drug use. There are no occupational hazards.

STATUS PRAESENS:

A condition of moderate severity. Consciousness is clear. Body temperature is normal (36.6). He understands the addressed speech. Has grade 4 obesity. Height 173 cm, weight 199 kg.

Skin, visible mucous membranes of pink color, normal moisture; subcutaneous fat is overdeveloped.

The occipital, cervical, parotid, anterior cervical, submandibular, supraclavicular, subclavian, axillary, inguinal and popliteal lymph nodes are not palpable.

Mild edema is defined in the ankle joint. Muscle development and tone are normal. Tremors and tremors of individual muscles are absent. Deformation of the bones and changes in the terminal phalanges of the fingers and feet are not detected. The configuration of the joints is normal, the skin color and local temperatures in the area of ​​the joints are also normal. There is no spinal curvature.

Respiratory organs: The chest is hypersthenic. Breathing type - mixed, breathing rate - 21 per minute, breathing through the nose is free; silent, rhythmic, moderate depth. On palpation, the chest is painless, the right and left halves evenly participate in the act of breathing. The lower border of the lungs is within normal limits. Percussion - clear pulmonary sound. Auscultatory - vesicular breathing, no wheezing.

Bodies of the CCC:

The boundaries of the relative dullness of the heart:

Left: in the 5th intercostal space on the mid-clavicular line

Right: in the 4th intercostal space 1 cm outward from the right edge of the sternum

Upper: on the 3rd rib, on the left peri-sternal line.

The configuration of the heart is normal. The width of the vascular bundle in the second intercostal space is 7 cm. Auscultation: heart sounds are clear, clean, rhythmic, the accent of the second tone at the point of aortic valve auscultation. HR-95. Noises and pathological rhythms are not heard. No splitting or bifurcation of tones was found. There is no pericardial rubbing noise. A / D 140/90 mm. rt. Art.

Digestive organs: Tongue moist, clean. The mucous membrane of the inner surface of the lips, cheeks, and the palate is pink, clean. The tonsils are not enlarged. The abdomen is of the correct shape, normal size, on palpation - soft, painless. Evenly participates in the act of breathing. There is no visible peristalsis of the stomach and intestines. The pancreas is painless on palpation, the size of the liver according to Kurlov:

)10cm

)9cm

)8 cm

The lower edge of the liver at the level of the costal arch, rounded, soft, painless; the gallbladder is not palpable. The Shchetkin-Blumberg phenomenon is negative.

Organs of the genitourinary system: On examination, the lumbar region is not changed, the kidneys are not palpable; the tapping symptom is negative. Kidneys, bladder are not palpable. There are no dysuric disorders. Primary and secondary sexual characteristics are formed according to gender and age. There are no growth disorders.

The thyroid gland is not visible, not palpable.

NEUROLOGICAL STATUS

Consciousness is clear. The patient is oriented in time, place and space. Dysarthria, while speech activity is increased.

Meningeal symptoms: Kernig's symptoms are negative, upper, middle and lower Brudzinski symptoms are negative. There is no stiffness of the neck muscles. Ankylosing spondylitis, Gordon's syndrome are absent.

Cranial nerves.

I pair - olfactory nerves.

Odors distinguish and differentiate from both nostrils.

II pair - the optic nerve.

A decrease in visual acuity is not noted. Color discrimination is not disturbed. There is no loss of visual fields. The fundus was not examined.

ΙΙΙ, ΙV, VI couples - oculomotor, block, abducens nerves.

The eye slits are symmetrical. The movements of the eyeballs are not limited in volume. The pupils are the same, the correct rounded shape. The reaction of the pupils to light is direct, friendly. The reaction to convergence is well expressed. Para - trigeminal nerve.

Palpation of the trigeminal points is painless. The movements of the lower jaw are not limited. The tone of the masticatory, temporal muscles is the same. Corneal, conjunctival reflexes are vivid, identical on both sides. II pair - facial nerve. The face at rest is asymmetric, there is a ptosis of the left corner of the mouth. The patient may close his eyes and furrow his eyebrows, wrinkle his forehead, bared his teeth (symmetrically). Lachrymation or dryness of the eyes is not observed pair - the vestibular cochlear nerve.

Hearing is not impaired, he understands whispered speech from 6 meters. Nystagmus is not observed., X pairs - lingopharyngeal and vagus nerves.

Swallowing and phonation are preserved. The soft palate is mobile. Palatine and pharyngeal reflexes live on both sides. Pair - accessory nerve.

There are no muscular atrophies and deformities of the sternocleidomastoid muscle. Head turns are saved.

XII pair - the hypoglossal nerve.

Speech is not clear, the tongue deviates to the left. There are no atrophies and fibrillar twitchings.

Motor sphere

When examining the muscles of the limbs and trunk, muscle atrophy is not detected, fibrillar and fascicular twitching is not detected. The movements of the upper limbs are possible in full:

· in the shoulder joint, movements are performed in the frontal plane - abduction up to 90 degrees and around the long axis of the shoulder - inward and outward rotation of 20 degrees. In the sagittal plane - flexion up to 130 degrees, extension up to 35 degrees. The arm extended forward to a horizontal position can be pulled back to an angle of 120 degrees and brought to the side of the opposite arm (towards the midline of the body) to an angle of 30 degrees.

· In the elbow joint, the flexion of the forearm is performed up to an angle of 140 degrees.

· In the wrist joint, movements are performed towards the palmar surface - palmar flexion of the hand to 50 degrees, to the rear - dorsiflexion (or dorsal extension) to 50 degrees, deviation of the hand to the radial side (abduction) - 15 degrees and ulnar (adduction) - 35 degrees ... Pro-backward movements of the hand (turning inward and outward) together with the forearm are performed within 80 degrees in either direction.

No phenomena of a cogwheel, a folding knife, or plastic hypertonicity were found. Strength in the muscles of the shoulder, forearm, hand and fingers of the right hand 5 points, the left hand - 4 points. Lower limb movements are possible in full:

· Flexion-extension movements are performed in the hip joint from the sagittal plane: flexion up to 120 degrees, extension, up to 10 degrees. In the frontal plane, abduction up to 30 degrees and adduction up to 30 degrees are performed. Rotational movements are determined in the position of full extension of the hip or when flexing it in the hip joint at an angle of 90 degrees.

· The range of these movements is within 45 degrees in one (internal rotation) and the other (external rotation) sides. Further movements in the hip joint are possible, but they are performed with the pelvis.

· In the ankle joint: plantar flexion up to 45 degrees, dorsiflexion (extension) up to 25 degrees. Adduction and abduction of the forefoot within 30 degrees, carried out by movement in the small joints.

The strength of the muscles of the left thigh, lower leg and foot is 4 points, the strength of the right thigh, lower leg and foot is 5 points. The pace of movement is sufficient.

Baret test: upper and lower positive on the left.

Reflex sphere

Deep reflexes from the hands:

flexion-elbow (C 5-C6) - is, alive, stronger on the left

wrist (C 5-C8) - yes, alive, stronger on the left

extensor ulnar - is, alive, stronger on the left

upper (D 7-D8) - yes, lowered on the left

medium (D9 - D10) - yes, lowered on the left

lower (D11-D12) - yes, lowered on the left

Deep reflexes from the legs:

knee (L 3- L4) - yes, alive, stronger on the left

Achilles (L5 - S1) - yes, alive, stronger on the left

Pathological reflexes of oral automatism are absent.

Pathological foot reflexes:

Babinsky's symptom(reflex extension of the toes with dashed irritation of the sole) negative

Rossolimo symptom(reflex flexion of the II-V fingers as a result of a short blow to their tips with a hammer) negative

Ankylosing spondylitis-Mendel's symptom(flexion of II - V fingers when tapping with a hammer on the antero-outer surface of the back of the foot) negative

Zhukovsky's symptom(plantar flexion of the II - V fingers when tapping with a hammer on the sole under the toes) is negative.

Oppenheim's symptom(as a result of holding the thumb pad with pressure on the front surface of the tibia from top to bottom, reflex extension of the thumb is observed) negative.

Gordon's symptom(as a result of squeezing the mass of the gastrocnemius muscle with the hand, reflex extension of the thumb is observed) negative.

Pussep's symptom(abduction of the V toe with dashed irritation of the outer edge of the foot), negative.

Coordinating sphere

The gait is not disturbed.

Static samples:

Romberg's pose - the patient is stable.

Dynamic probes:

Finger-nose test: performs correctly.

Calcaneal knee test: performs correctly

Sensitive sphere

Hypesthesia in the left extremities.

Functions of the pelvic organs

The function is not broken.

Higher cortical functions

Cognitive functions preserved

DATA OF ADDITIONAL RESEARCH METHODS

1.General urine analysis:

erythrocytes +++ 250

bilirubin-

urea + 16

protein ++ 1g

density 1.025

leukocytes + 25

2.Urine analysis according to Nechiporenko: leukocytes-18000, erythrocytes 82000.

3.No helminth eggs were found.

1. Blood glucose 10.1 mmol / l
2. Blood chemistry:

Albumin 46.8 g / l

Total protein 81g / l

Cholesterol 6.8 mmol / L

Triglycerides 1.44mmol / l

Urea 6.8 mmol / l

Total bilirubin 10.3 μmol / L

Direct bilirubin 3.4 μmol / L

1. SASS: PTV-19.1 sec, fibrinogen 2.8 g / l, APTT-31.2 sec, INR-1.54, RFMK-
2. EMF - negative.
3. Antibodies to HIV virus - not detected
4. ECG: Sinus rhythm 106, blockade of the anterior-left branch of the left leg p. His. Diffuse changes in the left ventricular myocardium.
5. Ultrasound of the abdominal cavity and kidneys: pathological echoes - signs of steatohepatosis, pancreatic lipomatosis.
6. Ultrasound of brachiocephalic vessels:

In PSMA, there is an increased peripheral resistance. CPD on the right SMA-80 mm. rt. Art., left SMA-106 mm. rt. Art. AD-198/119 mm. rt. Art.

SYNDROME DIAGNOSIS

1. Central paresis of the VII and XII pairs of FMN on the left:

· Descent of the left corner of the mouth

· Dysarthria

· Tongue deviation to the left

Central left-sided hemiparesis

· Strength in the muscles of the shoulder, forearm, hand and fingers of the left hand - 4 points. Muscle strength of the left thigh, lower leg and foot 4 points.

· Deep reflexes from hands saved S> D

· Abdominal: upper, middle, lower -decreased S> D

· Deep reflexes from knee legs, Achilles-preserved S> D

Sensory impairment in the form of hypesthesia in the left extremities.

Movement disorders in the form of central left-sided hemiparesis indicates a lesion of the pyramidal path, which begins in the right hemisphere in the neurons of the anterior central gyrus, then it goes into the inner capsule (anterior two-thirds of the hind thigh), then it passes in the middle part of the legs of the brain, descends through the base of the bridge and in the lower part of the medulla oblongata passes to the opposite side and approaches the anterior horns.

Central paresis of the VII and XII pairs of FMN indicates a unilateral lesion of the cortico-nuclear pathway passing in the knee of the inner capsule, in the middle part of the legs of the brain. The path crosses when approaching the nuclei.

Sensory disorders in the form of left-sided hemihypesthesia.

Pathways of superficial sensitivity (pain, temperature and partly tactile). The first neurons for all types of sensitivity lie in the spinal ganglia. Fibers from them through the posterior roots enter the posterior horns of the spinal cord of the same side, where the second neuron is located, then the fibers pass through the anterior commissure to the opposite side, obliquely rising 2-3 segments higher, and as part of the anterior sections of the lateral cords of the spinal cord go up , ending in the lower part of the outer nucleus of the optic hillock. This pathway is called the lateral spino-thalamic pathway.

The third neuron starts from the cells of the ventralateral nucleus of the optic tubercle, forming the thalamocortical pathway. Through the posterior third of the posterior leg of the internal capsule and then as part of the radiant crown, it is sent to the projection sensitive zone - the posterior central gyrus, to the cortex of the superior parietal region.

Paths of deep sensitivity (muscular-articular feeling, vibrational, and also partly tactile). Getting through the posterior roots into the spinal cord, the central fibers of the cells of the spinal ganglion (1 neuron) do not enter the posterior horns, but go to the posterior cords, in which they are located on the side of the same name. The fibers coming from the underlying sections (lower limbs) are located more medially, forming a thin bundle, or Gaul's bundle (fasciculus gracilis). Fibers carrying irritations from the proprioceptors of the upper extremities occupy the outer part of the posterior cords, forming a wedge-shaped bundle, or Burdakh's bundle (fasciculus cuneatum). Since fibers from the upper extremities pass in the wedge-shaped bundle, this path is mainly formed at the level of the cervical and upper thoracic segments of the spinal cord.

As part of thin and wedge-shaped bundles of fibers, they reach the medulla oblongata, ending in the nuclei of the posterior cords (nucl. Fasciculi gracilis et fasciculi cuneati), where the second neurons of the deep sensitivity pathways begin, forming the bulbothalamic pathway.

The paths of deep sensitivity cross at the level of the medulla oblongata, forming a medial loop (lemniscus medialis), to which fibers of the spinothalamic pathway and fibers coming from the sensory nuclei of the cranial nerves join at the level of the anterior sections of the bridge. As a result, conductors of all types of sensitivity, coming from the opposite half of the body, are concentrated in the medial loop. The conductors of deep sensitivity enter the ventralateral nucleus of the optic tubercle, where the third neuron begins. From the optic hillock as part of the thalamocortical pathway of deep sensitivity, through the posterior part of the posterior leg of the inner capsule, they come to the posterior central gyrus of the cerebral cortex, the superior parietal lobe and partly to some other parts.

ETIOLOGICAL DIAGNOSIS

Central paresis of the VII and XII pairs of FMN, movement disorders in the form of central left-sided hemiparesis, sensory disorders in the form of left-sided hemianesthesia indicate a one-sided location of the focus in the right hemisphere. Together with high cholesterol levels (6.8 mmol / L), arterial hypertension and metabolic syndrome, neurological syndromes may indicate a heart attack in the basin of the right middle cerebral artery, due to the formation of blood clots at the site of an atherosclerotic plaque.

CLINICAL DIAGNOSIS

Main: Ischemic stroke in the basin of the right MCA from 03/29/2015. Acute period. Atherothrombotic type. Central left-sided hemiparesis and hemihypesthesia. Central paresis of the VII and XII pairs of FMN on the left.

Concomitant: Hypertension III degree.

JUSTIFICATION OF CLINICAL DIAGNOSIS

The clinical diagnosis was made on the basis of:

Complaints: weakness in the left hand and its numbness, as well as impaired speech. PRAESENS: obesity grade 4.

Neurological status: central paresis of the VII and XII pairs of FMN on the left, movement disorders in the form of central left-sided hemiparesis, sensory disorders in the form of left-sided hemianesthesia. Absence of meningeal symptoms and headache.

Additional research methods: cholesterol 6.8 mmol / l, blood sugar 10.1 mmol / l, ultrasound of the brachiocephalic vessels: There is an increased peripheral resistance in PSMA. CPD on the right SMA-80 mm. rt. Art., left SMA-106 mm. rt. Art. AD-198/119 mm. rt. Art.

The leading clinical syndromes in this patient are central paresis of the VII pair of cranial nerves, movement disorders in the form of central left-sided hemiparesis, sensory disorders in the form of left-sided hemianesthesia.

Thus, taking into account all the above factors, syndromes and a slow onset of the disease, it can be argued that the patient has an ischemic stroke in the right MCA basin, of the atherothrombotic type.

DIFFERENTIAL DIAGNOSIS

neurological diagnosis stroke treatment

In connection with different therapeutic tactics for cerebral hemorrhage and cerebral infarction, the differential diagnosis of these diseases is of great importance. The classic signs of a hemorrhagic stroke are sudden, apoplectiform development of the disease, loss of consciousness, and instant onset of neurological symptoms (usually paralysis). A cerebral infarction is characterized by a period of precursors, a gradual dysfunction, and the preservation of consciousness at the onset of the disease. However, the disease does not always follow this classic pattern. In some cases, hemorrhage is not initially accompanied by loss of consciousness and neurological symptoms increase over time. Even more often there is an atypical course of ischemic stroke, which can begin extremely acutely, with the instant loss of other brain functions. Therefore, to diagnose the type of stroke, other signs must also be taken into account. Cerebral hemorrhage is characterized by a history of arterial hypertension with hypertensive crises. Ischemic stroke is preceded by heart disease, often accompanied by cardiac arrhythmias, and may have a history of myocardial infarction. The onset of the disease with hemorrhage is sudden, during vigorous activity, with emotional or physical stress. Cerebral infarction often begins during sleep or while resting. General cerebral, meningeal and autonomic symptoms are more pronounced in hemorrhagic stroke. Attachment to them of focal symptoms, signs indicating displacement and compression of the brain stem (oculomotor disorders, disorders of muscle tone, breathing, heart activity), also more often indicates a cerebral hemorrhage. High blood pressure, satisfactory heart function, tense, often slow pulse are characteristic of hemorrhagic stroke. Ischemic stroke usually occurs with normal or low blood pressure, heart sounds are muffled, the pulse is insufficiently filled, arrhythmia is often noted, and peripheral circulation in the extremities is not uncommon.

Also, the differential diagnosis is carried out with other diseases, manifested by the rapid development of neurological disorders. X-ray CT or MRI of the head can exclude many diseases (tumor, intracerebral hemorrhage, and others), which are sometimes clinically indistinguishable from a stroke and account for almost 5% of cases of sudden onset of symptoms of focal brain damage.

Dysmetabolic encephalopathy due to hypoglycemia, hyperglycemia, hypoxia, uremia, hyponatremia, or other disorders are usually manifested by impaired consciousness with minimal focal neurological symptoms (hyperreflexia, changes in tone, Babinsky's symptom), but sometimes they are accompanied by severe focal disorders (hemiparesis, aphasia), reminiscent of In their diagnosis, anamnestic data and the results of biochemical studies are of great importance, revealing the corresponding abnormalities in the blood plasma, the absence of changes on CT or MRI of the head, characteristic of a stroke. Alcoholic or, less commonly, alimentary Wernicke-Korsakoff encephalopathy may resemble a stroke in cases of rapid development of diplopia, ataxia, and confusion. The diagnosis of encephalopathy is confirmed by anamnestic data on alcohol abuse or nutritional disorders with thiamine deficiency, the presence in many cases of Korsakov amnestic syndrome and polyneuropathy, changes in MRI of the head in the area of ​​the sylvian aqueduct and medial nuclei of the thalamus, regression of symptoms during treatment with thiamine.

Traumatic brain injury can resemble a stroke and be combined with it. In cases of amnesia for trauma and the absence of external signs of head injury, traumatic intracranial hemorrhage or brain contusion is often regarded as a stroke. In such cases, the specification of the anamnesis and the results of CT or MRI of the head (if they are unavailable - X-ray of the skull, echoencephaloscopy and lumbar puncture reveal the traumatic genesis of the disease.

In people with epilepsy, seizures sometimes lead to impaired consciousness and post-seizure neurological disorders, such as hemiparesis (Tod's palsy), which can be mistakenly regarded as ischemic stroke. In these cases, it is of great importance to find out anamnestic data about previous seizures and the results of EEG, CT or MRI of the head. Stroke patients may develop epileptic seizures following a stroke, accompanied by a deepening neurological deficit, which can be regarded as a recurrent stroke. In such cases, only repeated CT or MRI of the head, showing the absence of new changes in brain matter, can rule out stroke.

In patients with migraine, in rare cases, migraine stroke may develop, which is usually manifested by homonymous hemionopsy. More often, patients with migraine develop "normal" strokes, and sometimes immediately before the development of a stroke or after an attack of migraine pain occurs, but the examination reveals a "normal" stroke, for example, an atherothrombotic stroke. One of the rare forms of migraine - basilar migraine - is manifested by visual impairment, dizziness, ataxia, bilateral paresthesias in the limbs, in the mouth and tongue, which resembles an ischemic stroke in the vertebrobasilar system. At a young age of patients, the absence of risk factors for stroke and the presence of previous migraine attacks, the diagnosis of stroke is unlikely, but an MRI of the head is necessary to exclude it.

TREATMENT PLAN

Mode - ward

Diet - No. 9

Basic principles of therapy:

) Normalization of blood pressure (hypo- or hypertensive drugs, depending on the initial blood pressure). The patient needs to lower blood pressure: beta-blockers (atenolol), ACE inhibitors (captopril, enalapril), Ca channel blockers (amlodipine). Enalapril 5-10 mg, by mouth or sublingually, 1.25 mg, IV slowly over 5 minutes;

) Correction of water-electrolyte balance and acid-base state;

) Prevention of pneumonia (breathing exercises (deep breathing) and early activation of the patient);

Special treatment for ischemic stroke includes: restoring blood flow to the affected area and maintaining normal brain function. To restore blood flow in the affected area: antiplatelet agents (acetylsalicylic acid, pentoxifylline) - acetylsalicylic acid from 80 to 325 mg / day; anticoagulants - sodium heparin under the skin of the abdomen, 5000 units every 4-6 hours for 7-14 days under the control of blood clotting time; vasoactive agents (cavinton, vinpocetine, nimodipine) - nimodipine 4-10 mg intravenously drip through an infusomat slowly (at a rate of 1-2 mg / h) under blood pressure control 2 times a day for 7-10 days, angioprotectors - ascorutin 200 mg / day

For normal brain function: vitamin E, glycine, ascorbic acid, piracetam.

Piracetam 4-12 g / day intravenous drip for 10-15 days .. Glicini up to 1 g per day under the tongue.

Tab.Aspirini ¼ at night.

Physiotherapy: phototherapy, laser therapy.

FORECAST

The greatest severity of the condition in patients with ischemic stroke is observed in the first 10 days of the disease, then there is a period of improvement, when the patient's symptoms begin to decrease. At the same time, the rate of recovery can be different. With a good and rapid development of collateral circulation, it is possible to restore function on the first day of a stroke, but more often after a few days. Mortality reaches 20-25%. In the case of this patient, the prognosis is favorable.

LITERATURE

1. Geltser, BI .. Propedeutics of internal diseases. General clinical research and semiotics: Lectures for students and novice doctors / B.N. Geltser, E F. Semisotova.-Vladivostok: Dalnauka, 2001. -420 p.

Gusev G.S. neurology and neurosurgery / E.I. Gusev, G.S. Burd, A.N. Konovalov.- SPb .: Medicine, 2000.-347 p.

Computer program “Cito! Analyzes "

Kulganov, Yu.V. Scheme of the case history / Yu.V. Kulganov, G.I. Bykova.-Vladivostok, 1996 -35 p.

Mikhailenko A.A. Topical diagnostics in neurology / A.A. Mikhailenko. Mikhailenko.-SPb .: Hippokrat, 2000.-264 p.

Fedotov, P.I. Atlas of photo illustrations to physical methods of clinical research of human internal organs in health and disease / P.I. Fedotov, N.A. Korosteleva.-Vladivostok .: Far East book publishing house, 1976 -261 p.

Kharkevich, D.A. Pharmacology: textbook / D.A. Kharkevich.-M .: GEOTAR-Media, 2006 - 736 s

Similar works on - Ischemic stroke in the right MCA basin. Acute period. Atherothrombotic type. Central left-sided hemiparesis and hemihypesthesia. Central paresis of the VII and XII pairs of FMN on the left

Of these, up to 30% falls on the localization of a negative focus in the vertebrobasilar vascular basin, but

the probability of death is much higher than with other localizations of the lesion focus.

Experts have also reliably established that up to 70% of the formation of a cerebral catastrophe was preceded by transient ischemic attacks. In the absence of adequate treatment, subsequently, an ischemic stroke with severe consequences was necessarily formed.

Characteristics of the vertebrobasilar system

It is this vascular structure that accounts for up to 30% of the total intracranial blood flow.

This is possible due to the peculiarities of its structure:

• paramedial arteries branching directly from the main arterial trunks;
• the bending arteries designed to supply blood to the lateral areas of the brain;
• the largest arteries, localized in the extracranial and intracranial cerebral regions.

It is this abundance of vessels and arteries with different lumen diameters, with a varied structure and anastomotic potential that determines the widest clinic of discirculation.

Along with the formation of clinical manifestations typical of transient ischemic attacks, a specialist can also detect atypical forms of ischemic stroke, which significantly complicates the diagnosis.

Reasons for development

Experts today are talking about the following most significant reasons for the formation of ischemic stroke:

1. Atherosclerotic lesion of intracranial vessels;
2. Features of the structure of the vascular bed of a congenital nature;
3. Formation of microangiopathies against the background of hypertensive pathology, diabetes and other diseases;
4. Severe compression of the arteries by pathologically altered cervical structures of the spine;
5. Extravasal compression, formed as a result of hypertrophied scalene muscle or hyperplastic transverse processes of the cervical segments of the spine;
6. Traumatization;
7. Lesions of the vascular wall by inflammatory phenomena - various arteritis;
8. Changes in rheological parameters of blood.

It is customary to distinguish between the following types of stroke in the vertebrobasilar region:

• in the basilar artery itself;
• in the region of the posterior cerebral artery;
• right-sided ischemic lesion;
• left-sided variant of cerebral catastrophe.

For the reason identified, the violation can be:

Symptoms

Most victims, upon careful questioning, can recall that the state of stroke was preceded by symptoms of transient ischemic attacks: previously uncharacteristic dizziness, unsteadiness when walking, pain in the head of a local nature, memory impairment.

If a person does not contact a specialist on time or in the absence of treatment, the symptoms of a stroke increase many times over. Their severity is largely determined by the localization of the negative focus, the extent of damage to the brain structures, the initial state of human health, and the adequacy of collateral blood supply.

1. Illusory perception by the patient of his own and external movements due to severe dizziness;
2. Inability to maintain an upright position - static ataxia;
3. Various severity of pain in the occipital region of the head, sometimes with irradiation to the region of the neck, eye sockets;
4. Some visual disorders;
5. The possibility of the formation of drop attacks - a person suddenly feels the maximum severity of weakness in the lower extremities and falls;
6. Significant memory impairment.

In the presence of one symptom or their combination, it is recommended to immediately consult a neurologist and the necessary list of diagnostic procedures. Ignoring the transient ischemic attack preceding cerebral catastrophe can lead to very serious complications in the future.

Diagnostics

In addition to carefully collecting anamnesis and conducting a diagnostic study, the specialist makes a diagnosis. Mandatory diagnostic procedures:

• dopplerography;
• duplex scanning;
• angiography;
• CT or MRI of the brain;
• contrast panangography;
• radiography;
• a variety of blood tests.

Only the entire completeness of the data allows for an adequate differential diagnosis of stroke in the vertebrobasilar basin.

Treatment

Stroke requires mandatory transportation of the victim to the conditions of a neurological hospital for complex treatment

1. Thrombolytic therapy - modern drugs are injected into the bloodstream, contributing to the fastest dissolution of the embolus that blocked the lumen of the intracranial vessel. The decision-making falls on a specialist who takes into account all the variety of indications and contraindications to the procedure.
2. To lower the parameters of blood pressure in the case of a hypertensive crisis, a person is administered antihypertensive medications.
3. Neuroprotective agents are called upon to maximally improve blood circulation in the brain and accelerate their recovery.
4. Antiarrhythmic drugs are prescribed to restore an adequate heart rate.

In the absence of positive dynamics from the ongoing conservative therapy of stroke, the neurosurgeon makes a decision to perform a surgical intervention - to remove the thrombotic mass directly from the area of ​​the damaged vessel.

Prophylaxis

As you know, the disease is easier to prevent than to deal with the treatment of its complications later. That is why the main efforts of specialists are aimed at promoting preventive measures to prevent strokes:

• correction of the diet;
• daily intake of the recommended antihypertensive and antiarrhythmic drugs, anticoagulants;
• constant monitoring of pressure parameters;
• taking modern statins;
• an annual full range of diagnostic procedures for persons at risk for the formation of a stroke;
• in the case of a blockage of an intracranial vessel with atherosclerotic or thrombotic masses - the appropriate surgical tactics of treatment.

The prognosis of stroke in the vertebrobasilar basin in the case of adequate therapeutic measures is very favorable.

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Ischemic stroke in the vertebrobasilar basin

A disease such as ischemic stroke of the brain is the main cause of disability in our time. The pathology has a high mortality rate, and in surviving patients it causes severe consequences of the cerebrovascular type. There are different reasons for the development of the disease.

What is vertebrobasilar insufficiency

The arteries of the spine emerge from the subclavian vessels located in the upper part of the sternum cavity and pass through the openings of the transverse processes of the vertebrae of the neck. Further, the branches go through the cranial cavity, where they are connected to one basilar artery. It is localized in the lower part of the brain stem and provides blood supply to the cerebellum and occipital region of both hemispheres. Vertebrobasilar syndrome is a condition characterized by a reduction in blood flow in the vertebral and basilar vessels.

Pathology is a reversible impairment of cerebral function that occurs as a result of a decrease in the blood supply to the area fed by the main artery and vertebral vessels. According to ICD 10, the disease is called "vertebro-basilar insufficiency syndrome" and, depending on concomitant disorders, may have a code P82 or H81. Since the manifestations of VBI can be different, the clinical symptoms are similar to other diseases, due to the complexity of diagnosing the pathology, the doctor often makes the diagnosis without proper justification.

Causes of ischemic stroke

The factors that can cause ischemic stroke in the vertebrobasilar basin include:

1. Embolism of various origins in the vertebrobasilar region or compression of the subclavian artery.
2. Arrhythmia, in which thrombosis develops in the atria or other parts of the heart. At any time, the blood clots can disintegrate into pieces and enter the vascular system along with the blood, causing blockage of the arteries in the brain.
3. Atherosclerosis. The disease is characterized by the deposition of cholesterol fractions in the arterial walls. As a result, the lumen of the vessel narrows, which entails a decrease in blood circulation in the brain. In addition, there is a risk that the atherosclerotic plaque will crack, and the cholesterol released from it will block an artery in the brain.
4. The presence of blood clots in the vessels of the lower extremities. They can be divided into segments and, together with the bloodstream, enter the cerebral arteries. By causing difficulty in the blood supply to the organ, blood clots lead to a stroke.
5. A sharp decrease in blood pressure or hypertensive crisis.
6. Compression of the arteries that supply blood to the brain. This can happen during carotid artery surgery.
7. Strong blood clotting caused by the growth of blood cells leads to obstruction of the vessels.

Signs of a cerebral infarction

The disease is an acute disturbance of cerebral blood supply (stroke ischemic) with the subsequent development of signs of a neurological disease, which persist for up to a day. With transient ischemic attacks, the patient:

1. temporarily loses sight;
2. loses sensitivity in any half of the body;
3. feels stiffness in the movements of the arms and / or legs.

Symptoms of vertebrobasilar insufficiency

Ischemic cerebral stroke with localization in the vertebrobasilar basin is perhaps the most common cause of disability in people under 60 years of age. Symptoms of the disease differ and depend on the localization of the violation of the main functions of the vessels. If blood circulation was impaired in the vertebro-basilar basin, the patient develops the following characteristic symptoms:

• dizziness of a systemic nature (the patient feels as if everything around him is crumbling);
• chaotic movement of the eyeballs or its limitation (in severe cases, complete immobility of the eyes occurs, squint is formed);
• deterioration in coordination;
• tremor while performing any action (trembling of the limbs);
• paralysis of the body or its individual parts;
• nystagmus of the eyeballs;
• loss of sensitivity in the body (as a rule, it occurs in one half - on the left, right, below or above);
• sudden loss of consciousness;
• irregularity of breathing, significant pauses between inhalation / exhalation.

Prophylaxis

The human cardiovascular system is constantly under stress as a result of stress, so the risk of stroke increases. With age, the threat of thrombosis of the head vessels increases, so it is important to prevent ischemic disease. To prevent vertebrobasilar insufficiency from developing, you should:

• to refuse from bad habits;
• with hypertension (high pressure), it is imperative to take medications to normalize blood pressure;
• promptly treat atherosclerotic stenosis, keep cholesterol levels normal;
• eat a balanced diet, adhere to a diet;
• control chronic diseases (diabetes mellitus, renal failure, arrhythmia);
• often walk on the street, visit dispensaries and medical sanatoriums;
• exercise regularly (exercise moderately).

Treatment of vertebro-basilar syndrome

Disease therapy is prescribed after the doctor confirms the diagnosis. For the treatment of pathology, the following are used:

• antiplatelet agents, anticoagulants;
• nootropics;
• analgesics;
• sedatives;
• correctors of blood microcirculation;
• angioprotectors;
• histaminomimetics.

Ischemic brain disease is dangerous because seizures (strokes) gradually become more frequent, and as a result, an extensive violation of the organ's blood circulation can occur. This leads to a complete loss of legal capacity. To prevent ischemic disease from becoming severe, it is important to seek the help of a doctor in a timely manner. In the treatment of vertebrobasilar syndrome, the main actions are aimed at eliminating circulatory problems. The main drugs that can be prescribed for ischemic disease:

• acetylsalicylic acid;
• Piracetam / Nootropil;
• Clopidogrel or Aggregal;
• Troxerutin / Troxevasin.

Alternative methods of treating ischemic disease can only be used as an additional measure. In case of ulceration of an atherosclerotic plaque or stenosis of the carotid artery, the doctor prescribes resection of the affected area followed by the imposition of a shunt. After the operation, secondary prophylaxis is performed. For the treatment of VHD (vertebro-basilar syndrome), therapeutic exercises and other types of physiotherapy are also used.

Physiotherapy

Vertebrobasilar insufficiency cannot be cured by drugs alone. Along with the drug treatment of the syndrome, therapeutic procedures are used:

• massage of the occipital region;
• magnetotherapy;
• manual therapy;
• therapeutic exercises to eliminate spasms;
• strengthening the spinal trunk, improving posture;
• acupuncture;
• reflexology;
• hirudotherapy;
• use of a cervical corset.

Treatment of cerebral ischemia

The most severe lesions in ischemic stroke that have arisen in the veterobasilar basin are brain stem injuries, since it contains vital centers - respiratory, thermoregulatory, and others. Violation of the blood supply to this area leads to respiratory paralysis, collapse and other life-threatening consequences. Ischemic stroke in the veterobasilar basin is treated by restoring impaired cerebral circulation and eliminating inflammatory foci.

A cerebral stroke is a disease that is treated by a neurologist in a hospital setting. With a therapeutic purpose in ischemic stroke of the vertebro-basilar basin, a drug method is used. During the treatment period, the following drugs are used:

• vasodilators to relieve spasms (nicotinic acid, Pentoxifylline);
• angioprotectors that stimulate cerebral circulation, metabolism (Nimodipin, Bilobil);
• antiplatelet agents to prevent thrombosis (Aspirin, Dipyridamole);
• nootropics for enhancing brain activity (Piracetam, Cerebozin).

Medical treatment of ischemic stroke, which happened in the vertebrobasilar basin, lasts for 2 years. In addition, an operative method of treating the disease can be used. Surgical intervention for vertebrobasilar syndrome is indicated for the third degree of ischemic disease, if conservative treatment did not give the expected effect.

According to ongoing studies, the severe consequences of ischemic stroke occurring in the vertebrobasilar basin occur in two cases. This happens if the treatment was not started in a timely manner or did not give results in the later stages of the development of the disease. In this case, a negative outcome of vertebrobasilar insufficiency can be:

First aid for stroke

If you observe symptoms of ischemic stroke in a person, call an ambulance immediately. Describe the symptoms as accurately as possible to the dispatcher so that the neurological team arrives on call. Next, give the patient first aid:

1. Help the person to lie down. At the same time, turn it on its side, substitute any wide container under the lower jaw in case of vomiting.
2. Measure your blood pressure. With ischemic stroke, which happened in the vertebrobasilar basin, the pressure is usually increased (approximately 180/110).
3. Give the patient an antihypertensive drug (Corinfar, Captopril, others). In this case, it is better to put 1 tablet under the tongue - this way the remedy will work faster.
4. Give the person with suspected ischemic stroke 2 tablets of a diuretic. This will help relieve the swelling of the brain.
5. To improve the metabolism of the patient's brain, give him a nootropic, for example, Glycine.
6. After the arrival of the ambulance team, tell the doctor exactly what drugs and in what dosage you gave the patient with ischemic stroke.

Video

The information presented on the site is for informational purposes only. Site materials do not call for self-treatment. Only a qualified doctor can diagnose and give recommendations for treatment based on the individual characteristics of a particular patient.

CVA in VBB: causes, symptoms, rehabilitation

Strokes in VBB rank second in the incidence of ischemic strokes (20% of cases)

Reasons for ONMK at VBB

Vertebrobasilar insufficiency or stroke can be caused by a number of reasons, including thromboembolism or hemorrhage (secondary, against the background of an aneurysm or injury). In general, stroke occurs due to an episode of ischemia (80-85% of patients), hemorrhage (15-20% of patients).

A number of risk factors for stroke are listed below:

• Advanced age
• Family history
• High blood pressure
• Cardiac ischemia
• Diabetes
• Smoking cigarettes
• Heart diseases
• Obesity
• Hypodynamia
• Alcoholism

The onset and duration of the symptoms of vertebral stroke depends, to a large extent, on the etiology. Patients with thrombosis of the basilar artery usually have an increase and decrease in a group of symptoms, as many as 50% of patients experience transient ischemic attacks (TIA) for several days to several weeks before the onset of occlusion.

In contrast, emboli are sudden, without a prodromal stage, with an acute and dramatic presentation.

Common Symptoms Associated with Vertebrobasilar Stroke

• Dizziness
• Nausea and vomiting
• Headache
• Decreased level of consciousness
• Abnormal oculomotor signs (eg, nystagmus, diplopia, pupil changes)
• Ipsilateral weakness of the muscles innervated by the cranial nerves: dysarthria, dysphagia, dysphonia, weakness of the muscles of the face and tongue.
• Loss of sensitivity in the face and scalp
• Ataxia
• Contralateral hemiparesis, tetraparesis
• Loss of pain and temperature sensitivity
• urinary incontinence
• blurring of visual fields
• neuropathic pain
• hyperhidrosis in the face and limbs

Features of the symptoms of stroke in VBD in the embolic variant

• fast onset - from the appearance of the first symptoms to their maximum development no more than 5 minutes
• movement disorders: weakness, awkwardness of movements or paralysis of the limbs of any combination, up to tetraplegia;
• sensory disorders: loss of sensation OR paresthesia of the extremities in any combination or spreading to both halves of the face or mouth;
• homonymous hemianopsia, or cortical blindness;
• disorders of coordination of movements; imbalance, instability;
• systemic and non-systemic dizziness in combination with double vision, swallowing disorders and dysarthria.

Symptoms that can also be seen in patients

• Horner's syndrome
• nystagmus (especially vertical)
• rarely hearing impairment.

Dizziness, ataxia and visual disturbances form the characteristic

pathology triad indicating ischemia of the brain stem, cerebellum and occipital lobes of the brain.

Sometimes the typical syndrome of vascular lesion in VBD can be combined with impairment of higher cerebral functions, for example, with aphasia, agnosia, acute disorientation.

Alternating syndromes with clearly localized foci within the VBD, for example, Weber, Miyard-Gubler, Wallenberg-Zakharchenko syndromes, rarely occur in their pure form.

A special form of acute cerebrovascular accident

in VBB there is an “archer's” stroke associated with mechanical compression of the vertebral artery at the C1-C2 level during extreme turn of the head.

At present, the mechanism of such a stroke is explained by the tension of the artery at the C1-C2 level when the head is turned, accompanied by a tear in the intima of the vessel, especially in patients with pathological changes in the arteries. In the case of compression of the dominant PA, there is no sufficient compensation of blood flow in the VBP. due to hypoplasia of the opposite vertebral artery or its stenosis, as well as the failure of the posterior connecting arteries, is a factor contributing to the development of an "archer's" stroke. One of the predisposing factors of this pathology is the presence of a Kimmerli anomaly in patients - an additional bone half-ring arch, which can squeeze the vertebral arteries above the arch of the first cervical vertebra.

ACVA in VBB is an emergency condition requiring hospitalization in a specialized vascular neurological department, treatment of ischemic stroke in VBB occurs in a hospital setting in a number of cases of the neuroreanimation department.

Rehabilitation after a stroke in the vertebrobasilar basin

Stroke rehabilitation plays a critical role in restoring brain function. Doctors and nurses play a critical role in rehabilitation.

nurses are often the first to offer initiation of therapy services because they have the widest possible involvement with the patient. Prior to discussing specific disciplines of therapy, addressing nursing issues in the care of patients with vertebrobasilar stroke.

may vary depending on the symptoms and the severity of the brain damage. Initial interventions include caring for the patient, maintaining the integrity of the skin, regulating bowel and bladder function, maintaining nutrition, and keeping the patient safe from injury.

Other important issues, in consultation with the attending physician, include the restoration of self-care swallowing function. In some patients, the severity of the neurological deficit makes it impossible to stand up, however, patients should be activated including their active participation in physical rehabilitation (physiotherapy exercises) and occupational therapy.

Positioning in bed and in the chair ensures patient comfort and prevents pressure sores complications. If the upper limb is flaccid or paretic, correct posture is critical to prevent shoulder subluxation and pain.

Nursing staff should train family members in caring for a stroke survivor. The patient's family members may not be familiar with stroke and its consequences. The training aims to educate the patient and family members about the importance of continuing rehabilitation and prevention of recurrence, about appropriate precautions, and continuing therapy after being discharged home.

Some patients have fluctuating signs and symptoms that are often related to position. Because of this possibility, precautions are necessary with measures that can be taken until the symptoms have stabilized.

The physical therapist is responsible for adjusting gross motor skills such as walking, maintaining body balance, the ability to move and change posture within a bed or wheelchair.

The exercise therapy doctor also develops an exercise program and instructs the patient in order to generally strengthen and increase movement. Education of the patient's family members and the use of lower limb prosthetics may be necessary to ensure functional mobility. Also shown is vestibular gymnastics.

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Stroke in the vertebrobasilar basin

With a stroke in the vertebrobasilar basin, the area of ​​the brain fed by the vertebral and basilar vessels is affected. More specifically, the cerebellum and the occipital part of both hemispheres are affected. The manifestations of the disease can be varied, so a reliable diagnosis can be made by a neurologist after receiving MRI or CT scans.

The mechanism of development of the disease

The vertebrobasilar system provides nutrients to the posterior parts of the brain, the optic tubercle, the Varoliev pons, the cervical spinal cord, the quadruple and the cerebral peduncles, 70% of the hypothalamic region. There are many arteries in the system itself. They have not only different sizes and lengths, but also differ from each other in structure. There are several types of the disease, and they all depend on the location of the lesion:

• right-sided ischemia;
• left-sided ischemia;
• damage to the basilar artery;
• damage to the posterior artery of the brain.

The mechanism of development of the disease is quite simple. As a result of any congenital pathology or altered blood composition, the arteries feeding a specific segment of the brain are narrowed. The patient has accompanying symptoms. If the visual hillock does not receive enough nutrition, then the patient will see worse, if the cerebellar region is affected, then the person's gait becomes shaky. Very often people with cervical osteochondrosis suffer from this disease.

The reasons for the development of a stroke in the vertebrobasilar basin

Formally, all factors influencing the development of stroke can be divided into congenital and acquired. Congenital includes those pathologies that are present in the human body from the beginning of his life. They also include a genetic tendency to atherosclerosis and the accumulation of cholesterol.

The acquired factors completely depend on the person's lifestyle. The presence of excess weight provokes the formation of excess cholesterol, which leads to blockage of blood vessels. Visceral fat has a similar effect. It is deposited not only around the organs of the trunk, but also next to the spine. As a result, excess weight begins to physically interfere with normal blood flow. The main reasons for the development of this type of stroke are:

• arrhythmia;
• embolism;
• atherosclerosis;
• thrombosis;
• thickening of the blood;
• mechanical clamping of the arteries;
• dissection of arteries.

The listed factors most often provoke various circulatory disorders. The cause of the disease greatly affects the treatment plan. If the problem is overweight, then it is enough for the patient to go on a diet, but with atherosclerosis, this approach will practically not help. But in all cases, to speed up recovery, the patient will have to take specialized medications.

Symptoms of an attack

Symptoms of ischemic stroke in the vertebrobasilar basin are similar to many other brain lesions. This is the main problem in the diagnosis of neurological diseases. Without a hardware examination, it will not be possible to diagnose the patient. Circulatory disorders are always acute. The symptoms are most pronounced at the onset of the attack, but within 3-4 days they subside. With transient ischemic attacks, the patient complains of the following:

• loss of vision;
• lack of sensitivity in any particular part of the body;
• problems with coordination and control of limbs;
• dizziness;
• disordered breathing rhythm;
• strange movements of the eyeball, unregulated patients.

How does vertebrobasilar stroke manifest in children?

Previously, it was believed that circulatory diseases of the brain occur only in older people, but numerous studies refute this information. Insufficiency of VBP occurs in children from 3 years of age. Most often, the cause of pathology is congenital anomalies in the structure of blood vessels. They can occur while still in the womb or as a result of trauma during childbirth. Also, this ailment is provoked by spinal injuries during sports. There are certain signs, thanks to which diagnosing a stroke or insufficiency of the vertebral basin is not a friend. Symptoms of the disease include:

• constant sleepiness;
• posture problems;
• fainting and nausea in stuffy rooms;
• tearfulness.

There are certain medical conditions that lead to stroke. In any case, at the first sign of illness, parents should take the child for a medical examination. If, as a result of the diagnosis, this ailment is revealed, then drug treatment should be started. There is no need to think that without drug therapy, circulatory disorders of the brain will pass. Blood flow in the arteries cannot be restored on its own.

Methods for diagnosing the disease

A stroke of this type, like the very insufficiency of the vertebrobasilar basin, is very difficult to diagnose. This is due to the fact that the disease manifests itself in different ways in different people. In addition, some patients cannot distinguish specific manifestations of the disease from subjective discomfort. As a result, when collecting anamnesis, the doctor cannot understand what specific disease he is looking for. In addition, the general symptoms of brain diseases are similar. The following diagnostic techniques are used:

• MRI or CT. Magnetic resonance imaging allows you to get a more detailed picture of the structures of the brain, but it cannot be done if the patient has implants in the mouth. For such cases, there is computed tomography. Thanks to her, you can see bleeding and all the changes in the brain that appeared right after the attack.
• Angiography. Contrast is injected into the vessels, and then photographs are taken. This diagnostic method allows you to obtain extended information about the state of the vascular system and the basin in question as a whole. Any narrowing of the vessel diameter will be displayed on the images.
• X-ray of the spine. It is necessary to assess the general condition of the vertebrae.
• Infrared thermography. Allows you to obtain information about the thermal characteristics of a specific part of the body.
• Functional tests. They will help to determine whether I am seriously affected by any area of ​​the brain after a circulatory disorder.
• The study of blood in the laboratory.

Treatment of vertebrobasilar stroke

A patient who has experienced an attack of acute circulatory disorders must be admitted to the hospital. There they begin to give the patient drugs that improve blood microcirculation. The danger of the disease lies in the fact that attacks become more frequent over time. If a person tries to be treated according to any method found somewhere, then he risks becoming disabled due to extensive cerebral hemorrhage. With a stroke, the following groups of drugs are prescribed:

• analgesics;
• nootropics;
• anticoagulants;
• angioprotectors;
• sedatives;
• histaminomimetics;
• antiplatelet agents.

Analgesics are needed to relieve pain. It is impossible to use narcotic drugs to eliminate pain in patients with a stroke. Nootropics stimulate the brain. Their doctors are prescribed to improve the metabolism inside the brain. Numerous studies have confirmed that nootropics can help prevent a second stroke.

Anticoagulants are prescribed for patients with viscous blood and a tendency to thrombosis. They can directly affect blood thrombin or disrupt the synthesis of this element in the liver. Antiplatelet agents have similar properties. After a stroke, patients are often unable to sleep well, so mild sedatives are prescribed.

Histaminomimetics are prescribed for damage to the cerebellum. They make the histamine receptors work more actively, which leads to the normalization of the functions of the vestibular apparatus. You cannot prescribe medicines on your own. This is what the doctor is doing. As for traditional medicine, prescriptions should be used as adjunctive therapy, and not instead of nootropics or angioprotectors.

Prophylaxis

Preventing a stroke is much easier than recovering from a stroke. It is advisable to start preventive measures immediately after circulatory failure has been detected. Also, people with a hereditary tendency to vascular pathologies should take care of their health. To prevent further deterioration of the cardiovascular system, it is necessary:

• To refuse from bad habits.
• Normalize the daily routine.
• Try to eat less fatty and salty foods.
• Do sports every day.
• Try to be outdoors more often.
• Walk 6-7 km a day.
• Track blood cholesterol levels.
• Treat in a timely manner all diseases affecting the state of blood vessels and blood pressure.

When it comes to bad habits, doctors talk about more than just smoking and alcohol. Lack of nutritional culture is another problem for patients at risk. Not only do people eat too much fatty foods, they overeat all the time. This is also harmful to health. With regard to daily sports, this includes light stretching and exercises. After hard and professional training, a person must give the muscles time to recover.

Walking in the fresh air will help avoid hypoxia. They promote the elimination of toxins from the body and help cells to renew themselves. As for the distance, it is desirable that it be at least 5 km. Ideally, to maintain a good condition of the cardiovascular system, a person should walk at least 8 km per day.

Weakness in the right hand

Severe limitation of active movements

Contact with the patient is difficult due to aphatic disorders, anisognosia.

There are no complaints from other bodies and systems.

05/05/11 - for the first time an increase in blood pressure (BP) up to 160/100 mm. rt. Art., previously blood pressure was not controlled. She did not ask for help.

05/10/2011 - against the background of a hypertensive crisis (180/110), an ischemic stroke developed in the basin of the left middle cerebral artery with deep right-sided hemiparesis up to plegia in the hand, elements of sensory-motor aphasia. She was hospitalized by the ambulance team in the district hospital.

20.g. - MRI showed signs of acute ischemic stroke in the LMA basin, obstructive hydrocephalus with a block at the level of the cerebral aqueduct, which was a consequence of a previous heart attack in the LMA basin.

May 21, 2011 - examined by a neurosurgeon - does not need neurosurgical correction.

August 2011 - was treated at the City Hospital. Discharged with some improvement.

01/14/20112 - sent to the Central Clinical Hospital of the UZ for treatment and additional examination.

Acute rheumatic fever at age 10 (June 1993)

Viral hepatitis, tuberculosis, sexually transmitted diseases - denies

Childhood infections - denies

Other past illnesses: bronchitis, pneumonia (2010)

Hereditary diseases not established

Allergic history is not burdened

Hemotransfusions were not performed.

The medical history is not burdened.

General condition - moderate severity

The skin is clean, normal color

Rhythmic heart sounds, accent of II tone on the aorta. HELL 135/80 mm. rt. Art. Heart rate 78 / min

Vesicular breathing is auscultatory in the lungs, no wheezing

Palpation of the abdomen is soft, painless. Liver at the edge of the costal arch

Physiological functions - no peculiarities

No peripheral edema

Stool and urination is controlled

The tapping symptom is negative on both sides.

Meningeal symptom complex negative

Eye slits and pupils D = S, converging strabismus due to the left eye. The movement of the eyeballs in full. Pupil reaction to light of medium vividness. Installation nystagmus

Central paresis of facial muscles on the right

The tongue is slightly deviated to the left. The pharyngeal reflex is preserved. Elements of sensory aphasia

Muscle tone in the right limbs is increased in a spastic manner. There is a moderate increase in muscle tone in the spastic type and in the left extremities. Muscle strength in the right limbs is reduced to 0-1 points in the arm, 1-2 points in the leg. Movements in the limbs are possible due to the proximal sections

Tendon and periosteal reflexes from hands D> S, high, with an extended zone of evocation; from legs D> S, high, polykinetic. Pathological foot and carpal phenomena on both sides

No convincing sensory disturbances have been identified

Emotionally labile. Dysphoria. Elements of anosognosia

Diagnosis on admission

Condition after an ischemic stroke in the LSMA pool with gross right-sided hemiparesis in the hand up to plegia, elements of sensory-motor aphasia, cerebrospinal fluid-hypertensive syndrome.

Combined rheumatic mitral disease with a predominance of insufficiency.

Examination plan and results

Magnetic resonance imaging of the brain

Occlusive hydrocephalus was a consequence of a heart attack in the basin of the left middle cerebral artery, as a consequence of prolonged ischemia - the formation of an adhesions with a block at the level of the aqueduct of the brain.

Sclerotic changes in the walls of the aorta, cusps of the aortic and mitral valves. Prolapse of the anterior and posterior cusps of the mitral valve II stage. with regurgitation I-II st. on the valve (the formation of mitral insufficiency against the background of rheumatic changes in the leaflets of the mitral valve). Dilation of the ascending aorta. Weakly expressed hypertrophy of the posterior wall of the left ventricle. Additional notochord in the lumen of the left ventricle, hemodynamically insignificant.

The rhythm is sinus. Correct. The horizontal position of the electrical axis. Signs of right atrial hypertrophy. Decrease in repolarization processes in the apical anterolateral region.

Doppler ultrasonography of the carotid arteries

No hemodynamically significant blood flow disturbances were found in all segments of the carotid basin on both sides.

Ultrasound examination of the abdominal organs

Diffuse changes in the parenchyma of the liver and pancreas without their increase. Cholesterosis of the walls of the gallbladder. Microurolithiasis. Right nephroptosis - I st. Focal neoplasms of the right adrenal gland.

Focal and infiltrative changes in the lungs were not identified. The roots are structural. Not enlarged. The sinuses are free. The diaphragm is clearly defined. Heart of regular shape and size. The aorta is not changed.

General blood analysis

Reactive thrombocytosis, leukocytosis, increased ESR

General urine analysis

Transient proteinuria due to damage to the basement membrane.

Lipid spectrum of blood

Hypercholesterolemia. Dyslipidemia: Type II-B

Blood chemistry

Hyperglycemia due to ischemia in the projection of the left

middle cerebral artery.

Blood clotting indicators

Within the physiological norm.

Lesion of the middle cerebral artery

Dyslipidemia type II-B

Heart failure II B, FC III

The defeat of the mitral valve with a predominance of insufficiency of stage I

Ischemic stroke in the basin of the left middle cerebral artery (05/10/11). Late recovery period. Arterial hypertension III degree, III stage. Heart failure II degree, FC III. Atherosclerosis. Dyslipidemia type II-B. Reactive thrombocytosis.

Post-rheumatic mitral disease with a predominance of Art I deficiency. Neoplasm in the adrenal gland.

Normalization of lifestyle, rehabilitation measures

Motor rehabilitation (full or partial recovery): range of motion, strength and dexterity in paretic limbs, balance function in ataxia, self-care skills

Speech rehabilitation: classes with a speech therapist-aphasiologist and neuropsychologist, exercises to restore writing, reading and counting, usually impaired in aphasia (and preserved in dysarthria), using "homework" for the afternoon

Psychological and social readaptation: creating a healthy climate in the family, developing an optimistic and at the same time realistic outlook on life, participating in cultural events within the social circle

Taking antidepressants: selective serotonin reuptake inhibitors.

Training in rehabilitation centers for stroke patients

Cardiomagnet 75 mg / day

Instant mortality in ischemic stroke is 20%

In 70% of patients, persistent defects of the motor and sensory spheres remain

In the absence of therapy, the recurrence rate is 10% per year

Antiplatelet drugs reduce the risk of recurrent stroke by 20%

Statins and a / hypertensive therapy (primarily ACE inhibitors!) Reduce the risk of relapse by 35%

50% of patients retain the ability to self-care

Up to 80% of patients recover the ability to walk

Almost 50% of patients with ischemic stroke die from myocardial infarction

Rehabilitation therapy (physical education, classes with a speech therapist, occupational therapy) is effective in 90% of rehabilitation cases

For life - favorable

For work - unfavorable, disability.

Ischemic stroke is a meteorological disease, the risk of which increases sharply in unfavorable weather.

Timokhin A.V., Zaritskaya N.A., Ph.D. Lebedinets D.V., Assoc. Lysenko N.V., prof. Yabluchansky N.I.

Kharkiv National University V.N. Karazin

Acute cerebrovascular accident in the basin of the left MCA by ischemic type. Right-sided hemiparesis. GB III Art, risk IV. Obesity II degree

Ischemic stroke - a complication of hypertension and atherosclerosis - is caused by diseases of the valvular apparatus of the heart, myocardial infarction, congenital anomalies of cerebral vessels, hemorrhagic syndromes and arteritis. Symptomatic therapy.

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Altai State Medical University

Head Department: Professor Schumacher G.I.

Teacher: assistant Gorbunova N.I.

Curator: student 408 gr. Tashtamyshev V.N.

Clinical history of the disease

Patient: ______________________

Barnaul-2008

FULL NAME. _________________________

Age: 49 (19.11.1958 year of birth)

Place of residence: ________________________________________

Family status: Married. Husband _________________________

Place of work: ___________________________________________

Date of admission to the hospital: 03/13/2008

The date of supervision is from 17.03.08. until 20.03.08.

Clinical diagnosis: Acute cerebrovascular accident in the basin of the left MCA by ischemic type. Right-sided hemiparesis and hemihypoanesthesia. Motor aphasia. GB III Art, risk IV. Obesity II Art.

COMPLAINTS

- For difficulty in speaking, during excitement, he cannot pronounce words clearly and clearly.

Headaches in the temporal and parieto-occipital regions, aggravated in the evening, as well as after sleep. The pains are acute, and occur in the left temporal region with a subsequent transition to the occipital and opposite temporal regions.

Periodic dizziness, tinnitus, nausea, retching,

To reduce superficial sensitivity in the right half of the body.

Glushkova Elena Gavrilovna, was born on November 11, 1958 in the Zalesovsky district of the Altai Territory in the village of Cheryomushkino. She grew and developed normally, she did not lag behind her peers in mental and physical development. She graduated from 10 classes of secondary school. In 1976 she studied as a machine operator, where she worked for 3 years. From 1979 to 2003 she worked as a commodity expert. In 2003 she became the director of the rural house of culture, where she still works.

Epidemic history Denies tuberculosis, viral hepatitis, venereal diseases. I was not in contact with infectious patients.

Bad habits: No

Allergic history: No.

Operations: cesarean section in 1990.

Blood transfusion in 1982 during childbirth.

The general condition of the patient is of moderate severity. Consciousness is clear, the position in bed is active. The skin is warm, moist, the turgor is preserved. The mucous membrane of the mouth, the conjunctiva is pink. Peripheral lymph nodes are not enlarged. The supraclavicular, ulnar, axillary, inguinal lymph nodes are not palpable. The patient's behavior is normal, he answers questions adequately, easily comes into contact. The physique is correct, the constitution is normosthenic, increased nutrition. No edema or subcutaneous emphysema. Height 144cm, weight 72kg. The presence of scars, defects in the head area is not observed. Type of hair growth for the female type. The hair is dark. Asymmetry of the chest, changes in the shape of the joints were not revealed. Full mobility in the cervical, thoracic and lumbar spine. The movements in the joints are preserved. Muscular system: on the left side of the body - muscles are in good shape, atrophy of pain on palpation is not. On the right: hypotonia, hypoesthesia. The thyroid gland is not enlarged, painless, and is not welded to the surrounding tissues.

Nasal breathing is free. The ribcage is of the correct shape; both halves are symmetrical, equally involved in the act of breathing. Vesicular breathing, no wheezing. RR = 16 / min. Palpation: the chest is painless, the resistance is good, the voice tremor is carried out with the same intensity. With comparative percussion, a clear pulmonary sound is heard at all points. With topographic percussion: the height of standing of the tops of the lungs is 4.5 cm on the right and left, the width of Krenig's fields on the left and on the right is 5 cm. The boundaries of the lungs are within normal limits.

Auscultation: at the junction of the sternum handle with the body, on the thyroid cartilage, on the spinous processes of the 1-3 cervical vertebrae, bronchial breathing is clearly audible, and at the standard points of comparative and topographic auscultation - vesicular breathing. No pathologies were identified. There are no wheezing, noises and crepitations.

On palpation seals along the veins, pain was not found. Pulse on both hands with a frequency of 65 beats per minute, coincides with the rhythm of heart contractions, the rhythm is correct, normal filling, synchronous on both hands, there is no pulse deficit. The arterioles of the nail phalanges do not pulsate. Blood pressure on both arms is 150/100 mm. rt. pillar. With auscultation of 1 and 2, the tones are muffled at all points of auscultation, the accent of the second tone above the aorta in the second m / r on the right. There were no pathologies on the part of the valvular apparatus of the heart. Noise is also not audible. On auscultation of the abdominal part of the aorta, stenotic murmur is not heard. The pulse is large, full, symmetrical, rhythmic, not tense.

Apical impulse in the 6th m / r, 1-1.5 cm outward from the midclavicular line.

Percussion revealed an increase in the left ventricle, relative and absolute dullness of the heart.

When examining the oral cavity, the tongue is moist, pink, without cracks and ulcerations, not coated with plaque, the papillae are not hypertrophied.

No dentures. The oral mucosa was unremarkable. The pharynx is not hyperemic, the tonsils are not enlarged. The act of swallowing is not disturbed. The abdomen is of the correct shape, symmetrical, not swollen, actively participates in the act of breathing, there are no visible pulsations, there is no visible peristalsis of the stomach and intestines. There is no bulging in the right hypochondrium.

Palpation... The temperature is the same on superficially symmetrical areas, the skin is moist. Subcutaneous fat is well expressed. The abdomen was soft, divergence of the rectus abdominis muscles, hernial orifices, no protrusions were found. There is a scar after a cesarean section. Symptom Shchetkin - Blumberg negative. With deep palpation according to Obraztsov - Strazhesko palpates the sigmoid colon in the left iliac region in the form of a smooth painless cord. The cecum could not be palpated. Other parts of the large intestine and stomach are not palpable. The pancreas and spleen are undetectable. The lower edge of the liver is located along the edge of the costal arch, the contour is smooth, soft-elastic consistency, painless. The size of the liver according to Kurlov is 9/8/7 cm. Free fluid in the abdominal cavity using percussion and the method of fluctuation was not revealed. On auscultation - the noise of intestinal motility. The stool is regular, shaped, without pathological impurities, of the usual color.

On examination of the lumbar region, swelling and edema were not found. The kidneys and bladder are not palpable. Urination is not difficult, painless, once a day. Pasternatsky's symptom is negative on both sides.

The patient's consciousness is clear. There are no obsessions, affects, behavioral features. Fully oriented in space and time, speech is correct, slightly inhibited. Reacts adequately to external stimuli. There is a disturbance of sleep and wakefulness. There are no meningeal symptoms.

I pair - n.olfactorius The sense of smell is not disturbed, there are no olfactory hallucinations.

II pair - n. opticus: vis 1.0 / 1.0, field of view

Ischemic stroke in the basin of the right middle cerebral artery

Ischemic stroke in the basin of the right middle cerebral artery has different statistics of the case of manifestation, but it is worth noting that this kind of stroke can become the root cause of various symptoms. Not all patients can recognize many of the symptoms of this disease. Since, for example, the arising acute gross motor deficits, which are signs of strokes, may not appear or are not pronounced.

What are the features of the symptoms of this disease?

In the presence of ischemic stroke in the basin of the right middle cerebral artery, it is possible to reveal the symptoms of lesions of the midbrain and cerebral hemisphere, depending on the location and conditions of collateral blood supply in the clinical picture. Quite often, you can find a combination of damage to the thalamus and the cerebral hemisphere, or isolated thalamic infarctions. It should be noted that in most cases, the symptoms of the disease in patients can be combined. The most common symptoms include visual damage, neuropsychological damage, and hemiparesis.

What are the features of the diagnosis of ischemic stroke in the basin of the right middle cerebral artery?

It is worth noting that often computed tomography does not allow detecting any ischemic modification in the parenchyma of the brain for a certain moment from the onset of strokes, precisely the time that is very important as the beginning of the cure for such diseases.

Thanks to the use of magnetic resonance imaging, it becomes possible to more accurately determine the presence and nature of any ischemic change in the main brain during strokes. After receiving the data after the performed magnetic resonance imaging, it becomes possible to detect early ischemic modification. Today, it has become possible to combine various modes, which makes it possible to determine a sharper, subacute and congenital ischemic change in the brain parenchyma.

What is the procedure for the treatment of ischemic stroke in the basin of the right middle cerebral artery?

To begin with, it is worth noting that the healing process is quite long and requires patience on the part of the patients. At the very beginning of the healing process, you should normalize the way of life, attend rehabilitation events. The motor process of rehabilitation includes strength and dexterity in each limb, self-service skills, all of which can be fully or partially rehabilitated. The speech rehabilitation process includes each session with specialists, in particular with speech therapists and neuropsychologists, each exercise necessary to restore ordinary reading or counting disorders. As for the psychological and social healing processes, it is necessary to create a healthy climate in families, participation in any cultural event within social circles.

Quite often, specialists in this field of activity prescribe their patients to use various kinds of antidepressants, which are selected individually for each patient. Much attention should be paid to this, because using your own assumptions about taking antidepressants can only lead to the appearance of various complications and side effects that can provoke undesirable consequences. That is why only the attending physician can prescribe the period of taking the drugs and the immediate dosage. The use of antiaggregates can reduce the risk of recurrence of a stroke, and in the absence of therapy, the disease can also return.

Clinical observations of a neurosurgeon, doctor of the highest category, candidate of medical sciences Zavalishin Evgeny Evgenievich

This clinical example shows how menacing the malignant course of ischemic stroke can look, the frequency of which reaches 25% of all ischemic strokes. This disease arises as a result of the closure of the lumen of the vessel and the lack of blood supply in a large area of ​​the brain matter.

Ischemic stroke in the right MCA basin, malignant course.

The presented operation is not a panacea, it is rather debatable, but in many cases (and in this case) it is a necessary operation. The purpose of this operation is to respond in time to the brain problem and create additional space for the edematous brain.

The brain is the most important integrative center, which has concentrated on itself all the control functions of the body, but reacts to any problems one-sidedly - edema, which is shown in these photographs.

Computed tomography 1 day from the onset of the disease

(lines indicate areas of ischemia, arrows indicate an extended thrombus in the vessel)

Intraoperative picture

(edematous brain, smoothed furrows, pale pink color)

Computed tomography after surgery

(the formed ischemic zone, the edematous substance of the brain does not infringe on the intact brain tissue, the arrows indicate the formed ischemic zone)

I do not undertake to discuss the ethical side of the issue of these photographs, but I want to convey to people the need for early prevention of stroke, a correct and active lifestyle, healthy food and full preventive medical examinations.

Ischemic strokes in the basin of the middle cerebral artery

Most strokes develop in the middle cerebral artery. Homonymous hemianopsia is characteristic, indicating damage to visual radiance. The eyeballs are directed towards the affected hemisphere11; on the opposite side, there is a weakness of the facial muscles of the lower half of the face and spastic hemiparesis (the hands suffer more than the legs). Muscle tone in paralyzed limbs may initially decrease, but spasticity develops after a few days or weeks. Sometimes sensory and movement disorders are limited to the contralateral arm and half of the face, and the leg and trunk are almost not affected. If the dominant hemisphere is damaged, motor and sensory aphasia is possible. With the defeat of the parietal lobe of the non-dominant hemisphere, complex disorders of sensitivity and perception disorders occur. The defeat of the right hemisphere is often accompanied by confusion, and the left hemisphere - depression in the later stages of the disease.

Cerebral edema can cause narrowing and occlusion of one or both of the posterior cerebral arteries; the consequence of this is hemianopsia or cortical blindness.

When the cervical part of the internal carotid artery is occluded, blood enters the anterior cerebral artery through the anterior communicating artery from the opposite side, thereby preventing a stroke in the frontal lobe and the medial surface of the hemisphere. Blood in the posterior cerebral artery comes from the vertebrobasilar system. Therefore, with occlusion of the internal carotid artery, stroke usually develops in the basin of the middle cerebral artery, and not the entire internal carotid artery.

Internal carotid artery stenosis can be suspected by a weakening of the pulse on it. However, the result of palpation, as well as the result of auscultation (see above), must be interpreted with caution - what seems to the doctor to be a normal pulsation of the internal carotid artery may in fact be an external pulsation. In diagnosis, a comparison of the pulse on the right and left carotid arteries helps: a significant weakening of the pulse on one side suggests occlusion of the common carotid artery of the same name. The occlusion of the internal carotid artery may be indicated by increased pulsation of the facial and superficial temporal arteries of the same side, since they are branches of the external carotid artery, into which all blood from the common carotid artery begins to flow. However, it is difficult to assess this symptom. Vascular murmur in the orbit area may indicate stenosis of the internal carotid artery.

"Ischemic strokes in the basin of the middle cerebral artery" - an article from the section Nervous diseases

Ischemic stroke

Ischemic stroke (cerebral infarction) is a clinical syndrome manifested by an acute violation of local brain functions lasting more than a day, or leading to death during this period. Ischemic stroke can be caused by insufficient blood supply to a certain area of ​​the brain due to decreased cerebral blood flow, thrombosis or embolism associated with vascular, heart or blood diseases.

Classification

There are different classifications of ischemic strokes, depending on the etiopathogenetic and clinical aspects, localization of the infarction zone.

By the rate of formation of neurological deficit and its duration

• transient disorders of cerebral circulation (PNMC) is a clinical syndrome presented by focal neurological and / or cerebral disorders, which develops suddenly due to an acute violation of cerebral circulation.

According to the severity of the patient's condition

• minor stroke - neurological symptoms are not significantly expressed, regresses within 3 weeks of the disease
• ischemic stroke of moderate severity - without clinical signs of cerebral edema, without disturbance of consciousness, with a predominance of focal neurological symptoms in the clinic
• severe stroke - with severe cerebral disorders, depression of consciousness, signs of cerebral edema, vegetative-trophic disorders, gross focal deficit, often dislocation symptoms

On pathogenesis (Research Institute of Neurology, Russian Academy of Medical Sciences, 2000)

• atherothrombotic stroke (including arterio-arterial embolism)
• cardioembolic stroke
• hemodynamic stroke
• lacunar stroke
• stroke by the type of hemorheological microocclusion

By localization of cerebral infarction

In accordance with the topical characteristics of focal neurological symptoms, for the affected arterial basin: internal carotid artery; the main artery and its distal branches; middle, anterior and posterior cerebral arteries.

Etiology and pathogenesis

The following are distinguished as local etiotropic factors of stroke:

• atherosclerosis of the main and intracerebral arteries. Soft, loose atheromatous plaques become a source of embolism, dense ones narrow the lumen of the arteries, restricting blood flow. A 60% decrease in cerebral blood flow is critical for the development of stroke.
• thrombus formation. The main stages of thrombus formation: damage to the endothelium of the vascular wall, slowing and turbulence of blood flow at the site of stenosis, increased aggregation of blood elements, coagulation of fibrin and a decrease in local fibrinolysis.
• cardiac pathology is the cause of 30 to 60% of strokes. This pathology includes damage to the heart valves, left ventricular hypertrophy, blood clots in the heart cavity, arrhythmias, myocardial ischemia.
• degenerative and deforming changes in the cervical spine (osteochondrosis of the spine, deforming spondylosis, anomalies of the craniocerebral region), leading to compression of the vertebral arteries with the development of strokes in the vertebral-basilar basin.
• rare vascular pathology: Takayasu's disease, Moyamoya, infectious arteritis.

The following are named as systemic factors contributing to the development of ischemic stroke:

1. violation of central hemodynamics:
   • cardiac hypodynamic syndrome - manifested by impaired blood circulation, heart rhythm, a decrease in the minute volume of blood and stroke volume, which leads to a decrease in blood flow in the arterial system of the brain, disruption of the mechanisms of autoregulation of cerebral circulation and the formation of thrombotic stroke or the development of cerebral ischemia by the type of cerebrovascular insufficiency ( hemodynamic stroke).
   • arterial hypertension - intensifies hemodynamics and leads to the development of arterio-arterial, cardiogenic embolism, or the formation of small (lacunar, microcirculatory) strokes.
   • arrhythmias are a factor in the development of arterio-arterial and cardiogenic embolisms. In combination with severe arterial hypertension, the risk of embolism is highest.
2. Other systemic factors include coagulopathy, erythrocytosis, and polycetemia.

Depending on the etiopathogenetic factors, ischemic stroke is subdivided into atherothrombotic, cardioembolic, hemodynamic, lacunar and stroke according to the type of hemorheological microocclusion.

• Atherothrombotic stroke (34%) usually occurs against the background of atherosclerosis of the cerebral arteries of large or medium caliber. Atherosclerotic plaque narrows the lumen of the vessel and promotes thrombus formation. Arterio-arterial embolism is possible. This type of stroke develops stepwise, with an increase in symptoms over several hours or days, often debuting in a dream. Often, atherothrombotic stroke is preceded by transient ischemic attacks. The size of the ischemic lesion focus varies.
• Cardioembolic stroke (22%) occurs when a cerebral artery is completely or partially blocked by an embolus. The most common causes of stroke are cardiogenic embolism in valvular heart disease, recurrent rheumatic and bacterial endocarditis, in other heart lesions, which are accompanied by the formation of parietal thrombi in its cavities. Often, an embolic stroke develops as a result of a paroxysm of atrial fibrillation. The onset of cardioembolic stroke is usually sudden, while the patient is awake. At the onset of the disease, the neurological deficit is most pronounced. Most often, a stroke is localized in the area of ​​blood supply to the middle cerebral artery, the size of the focus of ischemic damage is medium or large, and a hemorrhagic component is characteristic. A history of possible thromboembolism of other organs.
• Hemodynamic stroke (15%) is caused by hemodynamic factors - a decrease in blood pressure (physiological, for example, during sleep; orthostatic, iatrogenic arterial hypotension, hypovolemia) or a drop in cardiac output (due to myocardial ischemia, severe bradycardia, etc.). The onset of hemodynamic stroke can be sudden or stepped, at rest or in the active state of the patient. The sizes of heart attacks are different, localization is usually in the area of ​​adjacent blood supply (cortical, periventricular, etc.). Hemodynamic strokes occur against the background of pathology of extra- and / or intracranial arteries (atherosclerosis, septal stenosis of the arteries, abnormalities of the vascular system of the brain).
• Lacunar stroke (20%) 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, internal capsule, white matter of the semi-oval center, base of the pons), the size of the foci does not exceed 1.5 cm.General cerebral and meningeal symptoms are absent, there are characteristic focal symptoms (purely motor or purely sensitive lacunar syndrome, atactic hemiparesis, dysarthria or monoparesis).
• A stroke of the type of hemorheological microocclusion (9%) occurs against the background of the absence of any vascular or hematological disease of the established etiology. Stroke is caused by pronounced hemorheological changes, disturbances in the system of hemostasis and fibrinolysis. Scanty neurological symptoms in combination with significant hemorheological disorders are characteristic.

The cerebral ischemia process is dynamic and, as a rule, potentially reversible. The degree of ischemic damage depends on the depth and duration of the decrease in cerebral blood flow. When the level of cerebral blood flow is below 55 ml per 100 g of substance per minute, there is a primary reaction, which is characterized by inhibition of protein synthesis in neurons - the "marginal zone of ischemia". With cerebral blood flow below 35 ml per 100 g / min. anaerobic glycolysis is activated. This zone of dynamic changes in metabolism, the so-called "ischemic penumbra" or "penumbra" (eng. penumbra). Along with the existing functional changes in the structures of the brain, there are no morphological changes in the penumbra. Penumbra exists for 3-6 hours from the onset of the first clinical manifestations of cerebral ischemia. This period is a "therapeutic window" during which it is possible to limit the prevalence of heart attack; during this period of time, therapeutic measures are most promising. Cell death in the area of ​​the penumbra leads to the expansion of the infarction area. The final formation of the infarction zone is completed in 48 - 56 hours. In the area of ​​decreased cerebral blood flow below 20 ml per 100 g / min. a central zone of infarction is formed (the "nucleus" of ischemia), which is formed in 6 - 8 minutes. In this zone, energy metabolism disorders are irreversible, with the development of brain tissue necrosis. Cerebral ischemia leads to a series of interrelated pathobiochemical changes called "pathobiochemical cascade" or "ischemic cascade" (Gusev EI et al., 1997). According to V.I. Skvortsova (2000), its stages are:

• decreased cerebral blood flow.
• glutamate excitotoxicity (excitatory neurotransmitters glutamate and aspartate have a cytotoxic effect).
• intracellular calcium accumulation.
• activation of intracellular enzymes.
• increased synthesis of NO and the development of oxidative stress.
• expression of early response genes.
• long-term consequences of ischemia (reaction of local inflammation, microvascular disorders, damage to the blood-brain barrier).
• apoptosis is genetically programmed cell death.

Ischemic processes in the brain tissue are accompanied by cerebral edema. Cerebral edema develops a few minutes after the development of local ischemia, its severity directly depends on the size of the cerebral infarction. The starting point for the development of edema is the penetration of water from the intercellular space into the cells due to a violation of the permeability of cell membranes. After that, extracellular (vasogenic) edema joins the intracellular edema, which is caused by a violation of the blood-brain barrier with the accumulation in the damaged area of ​​under-oxidized products formed during anaerobic glycolysis. Intracellular and vasogenic edema leads to an increase in the volume of the brain and intracranial hypertension, which causes dislocation syndrome ("upper" insertion - insertion of the basal parts of the temporal lobe into the notch of the cerebellar sign with entrapment of the midbrain, and "lower" insertion - insertion into the foramen magnum of the cerebellar tonsils with compression of the lower parts of the medulla oblongata - the most common cause of death in patients).

Clinical picture

The clinical picture of ischemic stroke consists of cerebral and focal neurological symptoms.

General cerebral symptoms

General cerebral symptoms are characteristic of moderate and severe strokes. Disturbances of consciousness are characteristic - stunnedness, drowsiness or agitation, a short-term loss of consciousness is possible. Headache is typical, which may be accompanied by nausea or vomiting, dizziness, pain in the eyeballs, aggravated by eye movement. Convulsive phenomena are less common. Vegetative symptoms are possible: a feeling of heat, sweating, palpitations, dry mouth.

Focal neurological symptoms

Against the background of cerebral stroke symptoms, focal symptoms of brain damage appear. The clinical picture is determined by which part of the brain is damaged due to damage to the blood vessel supplying it.

Stroke in the basin of the left middle cerebral artery: the ratio of speech disorders with a variant of cerebral infarction

About article

The article examines the variants of speech disorders and variants of changes in the brain substance during stroke in the basin of the left middle cerebral artery (MCA), special attention is paid to aphasia and the variants that caused it, ischemic, as a rule, cerebral infarction. The effectiveness of a set of classes to improve speech is analyzed.

Research: to study the ratio of the volume of brain damage in stroke in the left MCA basin and the degree of speech impairment.

Material and methods: the study included 356 people with suspected acute cerebrovascular accident (ACVA), who were examined by a neurologist, and the neurological deficit was assessed. Later, if the condition of the patients allowed, they underwent speech therapy, in most cases - the next day after admission to the hospital. All patients on admission and the majority of patients underwent a CT scan of the brain in dynamics in order to confirm / exclude focal brain lesions and to clarify the extent of the lesion and localization of the pathological area.

Results: according to the results of CT of the brain, 32 (25.8%) out of 124 people showed typical ischemic changes in the LSMA basin, of which 7 - during the study in dynamics, i.e., upon admission, the changes were not yet obvious (initial stage stroke). The main comparison groups were 3 groups of patients: with dysarthria (20 people), motor aphasia (13 people) and sensorimotor aphasia (23 people). The comparison criteria were the volume and nature of the lesion, the state of consciousness, and the timing of speech restoration.

Conclusions: sensorimotor aphasia in ischemic cerebral infarction can occur both when a large area around the Sylvian groove of the dominant hemisphere is affected, and when a local lesion occurs in the area of ​​one of the speech cortical centers or the area of ​​white matter between them. Aphasic syndrome is more common in cryptogenic ischemic stroke, sensorimotor aphasia often occurs in recurrent strokes. Taking into account the less pronounced dynamics of speech restoration in the group of patients with sensorimotor aphasia, it is important for these patients to continue speech therapy classes after discharge in order to achieve significant / complete recovery.

Key words: stroke, left middle cerebral artery, aphasia, cerebral infarction, Broca's center, Wernicke's center, computed tomography, dysarthria.

For citation: Kutkin D.V., Babanina E.A., Shevtsov Yu.A. Stroke in the basin of the left middle cerebral artery: the ratio of speech disorders with a variant of cerebral infarction // RMZh. 2016. No. 26. WITH.

Left middle cerebral artery stroke: the correlation between speech disorders and cerebral infarction Kut'kin D.V., Babanina E.A., Shevtsov Yu.A. City Clinical Hospital No. 5, Barnaul

Background. The paper discusses speech disorders and variants of brain injury after left middle cerebral artery (MCA) stroke. Aphasia and underlying types of ischemic stroke are of special interest. The efficacy of speech therapy exercises is analyzed.

Aim. To study the correlation between brain injury severity after left MCA stroke and speech disorder degree.

Patients and methods. The study enrolled 356 patients with probable acute stroke who were examined by a neurologist to assess the severity of neurological deficiency. If the condition was satisfactory, the patient was examined by speech therapist. At admission and dynamically, the patients underwent brain CT to verify or to exclude focal brain injury and to specify lesion size and localization.

Results. Brain CT revealed typical ischemic lesions in the left MCA perfusion area in 32 of 124 patients (25.8%). In 7 patients, these lesions were not obvious (early stroke). Three study group were compared: patients with dysarthria (n = 20), motor aphasia (n = 13), or sensorimotor aphasia (n = 23). Comparison criteria were lesion size and localization, consciousness, and speech recovery time.

Conclusions. Sensorimotor aphasia after ischemic strokes may result from large lesions around Sylvian fissure as well as from local lesions of cortical speech center (s) or white matter between them. Aphasia is more common in cryptogenic ischemic strokes while sensorimotor aphasia is more common in recurrent strokes. Considering delayed speech recovery in sensorimotor aphasia group, these patients should proceed with the speech therapy after the discharge to achieve significant improvement or full speech recovery.

Key words: stroke, left middle cerebral artery, aphasia, cerebral infarction, Broca's area, Wernicke's area, computed tomography, dysarthria.

For citation: Kut'kin D.V., Babanina E.A., Shevtsov Yu.A. Left middle cerebral artery stroke: the correlation between speech disorders and cerebral infarction // RMJ. 2016. No. 26. P. 1747-1751.

The article discusses variants of speech disorders and variants of changes in the substance of the brain in stroke in the basin of the left middle cerebral artery

Introduction

Speech processes, as a rule, show a significant degree of lateralization and in most people depend on the leading (dominant) hemisphere. It should be borne in mind that in defining the dominant hemisphere responsible for speech, the approach linking dominance only with right-handedness or left-handedness is simplified. The profile of the distribution of functions between the hemispheres is usually diverse, which is reflected in the degree of speech disorders and the ability to restore speech. Many people exhibit only partial and unequal dominance of the hemisphere in relation to different functions. While speech function in right-handers (≥90%) and most left-handers (> 50%) is associated primarily with the left hemisphere, there are three exceptions to this rule:

1. Less than 50% of left-handed people have speech function associated with the right hemisphere.

2. Anomical (amnestic) aphasia can occur with metabolic disorders and volumetric processes in the brain.

3. Aphasia may be associated with damage to the left thalamus.

The so-called cross aphasia (aphasia caused by cerebral lesion ipsilateral to the dominant hand) is currently referred only to right-handers.

The area of ​​the cortex responsible for the function of speech is located around the Sylvian and Rolland furrows (MCA basin). The speech production is determined by four zones of this area, closely related to each other and located sequentially along the anterior anterior axis: Wernicke's zone (posterior part of the superior temporal gyrus), angular gyrus, arcuate bundle (DP) and Broca's zone (posterior part of the inferior frontal gyrus) (Fig. 12) .

DP is a subcortical fibers of white matter connecting Broca's area and Wernicke's area. There is evidence that in the left hemisphere, DP occurs in 100% of cases, while in the right hemisphere - only in 55%. A number of researchers believe that there are several pathways involved in providing speech function. Other authors have received reliable confirmation only of the role of DP.

The pathogenesis of dysarthric speech disorders is caused by focal lesions of the brain, different in localization. Complex forms of dysarthria are often observed.

Objective: to study the ratio of the volume of brain damage in stroke in the left MCA basin and the degree of speech impairment.

Material and methods

In 124 cases (every third patient) a preliminary diagnosis was made: stroke in the basin of the left middle cerebral artery (LSMA). This localization is most relevant in the study of aphasia in patients with stroke.

All patients on admission and the majority of patients underwent a CT scan of the brain (Bright Speed ​​16 tomograph) in dynamics in order to confirm / exclude focal brain lesions and clarify the extent of the lesion and localization of the pathological area.

According to the results of CT of the brain, 32 (25.8%) people out of 124 revealed typical ischemic changes in the LSMA basin, of which 7 during the study in dynamics, i.e., at admission, the changes were not yet obvious (the initial stage of stroke). In 5 (4.0%) cases, hemorrhages were revealed: left-sided medial hematomas and 1 case of subarachnoid hemorrhage (SAH). In 5 (4.0%) cases out of 124, infarctions of other localization (not in the LSMA basin) were detected (Table 1).

In 60 (48.4%) cases, patients were not hospitalized. In most cases, ACVA was not confirmed (there are no corresponding changes in CT and neurological status). The number of those who were not hospitalized in the ACVC department also included patients with various types of atrophy of the brain substance in combination with significant neurological symptoms, who refused the proposed hospitalization. A few patients were transferred to other hospitals, since they were diagnosed with traumatic changes in the skull, brain, neoplasms. Some of the patients were transferred to the neurology emergency department of another hospital, for example, with a diagnosis of osteochondrosis.

64 patients admitted to the stroke department with stroke had speech impairments (Table 2). The detailed nature of speech disorders is determined by a speech therapist. In 20 (31.2%) cases, the patients had dysarthria and the absence of aphasia. In 2 cases, dysarthria was accompanied by dysphonia and dysphagia. Aphasia was detected in 44 (68.8%) people, of whom in 7 cases it regressed by the time of consultation with a speech therapist the next day (in 2 cases, with regression of aphasia, ischemic heart attacks were detected). 3 people from the group with the sensorimotor variant of aphasia had severe dysarthria, 9 people - dysphagia. In 4 people from the group with motor aphasia, symptoms of dysarthria were also noted, in 1 case - severe dysarthria.

In patients with dysarthria without aphasia, 4 types of dysarthria were identified: extrapyramidal (3 cases), afferent cortical (1 case), bulbar (1 case), pseudobulbar (8 cases), in other cases it was difficult to clearly determine the type of dysarthria, the manifestations were mild ( Table 3).

In groups of patients with dysarthria and regression of aphasia within 24 hours, there is a slight predominance of men.

In the group of patients with sensorimotor aphasia (23 people), in 39.1% (9 people) of cases, patients with sensorimotor aphasia had a large infarction in the LSMA basin of the dominant hemisphere (Fig. 4-6). In 47.8% (11 people) of cases, small infarction was detected (Fig. 7).

The main comparison groups were 3 groups of patients: with dysarthria (20 people), motor aphasia (13 people) and sensorimotor aphasia (23 people). The comparison criteria were the volume and nature of the lesion, the state of consciousness, and the timing of speech restoration.

In table 4, in parentheses, cases of correspondence of the localization of pathological changes to the functional and anatomical zones are indicated (with sensorimotor aphasia - a vast area around the Sylvian groove; with motor aphasia - with Broca's center; with dysarthria - with local changes at the level of the midbrain, subcortical structures, and cortex).

It is often not possible to achieve a significant improvement in speech in patients with sensorimotor aphasia in the hospital (Table 6). Therefore, the speech therapist gives recommendations to each patient to continue classes at home.

results

These data are confirmed in studies of the aphasic syndrome conducted in the second half of the twentieth century, according to which patients who have survived a hemorrhagic stroke have opportunities to restore speech, and a favorable prognosis can be expected. In dynamics, the degree of speech impairment, as a rule, decreased against the background of complex treatment, including while maintaining hemodynamically significant stenosis of the internal carotid artery (according to ultrasound duplex scanning), but in the absence of recurrent stroke or severe hemorrhagic transformation.

conclusions

2. In patients with sensorimotor aphasia caused by stroke, more often than in other groups, deafened consciousness was noted, despite the fact that the size of the confirmed infarction was not large in more than half of the cases.

3. The actual boundaries of the speech centers individually, most likely, vary, therefore, the accuracy of the alleged anatomical lesion of the degree of functional impairment (aphasia) does not always coincide.

4. Full correspondence of the volume of the revealed cerebral infarction to the volume of speech disorders was observed in the group of patients with sensorimotor aphasia, when the infarction was large.

5. Aphasic syndrome is more common in cryptogenic ischemic stroke, sensorimotor aphasia often occurs in recurrent strokes.

6. Given the less pronounced dynamics of speech recovery in the group of patients with sensorimotor aphasia, these patients should continue speech therapy classes after discharge in order to achieve significant / complete recovery.

Ischemic stroke in the pool of the posterior cerebral arteries

article in PDF format

Etiology. The most common cause of isolated infarctions in the PCA pool is embolic occlusion of PCA and its branches, which occurs in 80% of cases (cardiogenic> arterio-arterial embolism from vertebral and basilar [syn: main] arteries> cryptogenic embolism). Thrombosis in situ is detected in PCA in 10% of cases. Migraine-related vasoconstriction and coagulopathies are the cause of cerebral infarction in 10% of cases. If isolated infarctions in the PCA basin in most cases are of a cardioembolic nature, then the involvement of the brain stem and / or cerebellum in combination with a heart attack in the PCA basin is most often associated with atherosclerotic vascular lesions of the vertebrobasilar basin (VBB). Arterial dissection involving PCA can be a very rare cause of a heart attack in this area. Regardless of the cause of the heart attack, it usually only partially captures the PCA pool.

the materials of the article "Ischemic stroke in the basin of the posterior cerebral arteries: problems of diagnosis, treatment" by I.А. Khasanov (physician of the neurological department for patients with acute cerebrovascular accidents), E.I. Bogdanov; Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan; Kazan State Medical University (2013) [read] or [read];

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