Algorithm of antithrombotic therapy in patients with ischemic stroke after systemic thrombolysis

Based on modern ideas about the mechanisms of development of ischemic stroke, neurologists at the Yusupov Hospital identify 2 main directions of pathogenetic therapy: improving the perfusion of brain tissue (the passage of blood through them) and neuroprotection (a set of measures aimed at improving the biochemical and restorative properties of the nerve cell).

Complex therapy of ischemic cerebral stroke

It is known that in the absence of adequate therapy, approximately 2 million neurons die within ten minutes of ischemia. Each stage of the ischemic cascade is a potential target for therapeutic intervention. The earlier neuroprotective treatment is started, the greater the chances of success, the less the degree of damage to the brain substance.

Doctors at the Yusupov Hospital begin complex therapy for ischemic stroke immediately after the patient is admitted to the neurology department and an accurate diagnosis is established. Neurologists draw up treatment regimens for patients with cerebral infarction individually, taking into account which vessel has impaired blood flow, the size of the ischemic focus, and how damaged the nerve cells around the area of ​​cerebral infarction are. Due to the fact that the clinic conducts research on modern drugs for the treatment of acute cerebrovascular accidents, patients at the Yusupov Hospital have the opportunity to receive the most modern drugs.

Drug treatment of acute ischemic stroke includes basic and specific therapy. Basic therapy consists of:

• measures to support respiratory and circulatory functions;
• correction of metabolic disorders and the volume of circulating fluid;
• blood pressure control.

The main goal of intensive care is to prevent oxygen deprivation of brain tissue and the associated increase in brain damage. To ensure adequate water-electrolyte balance and blood flow, doctors at the Yusupov Hospital provide infusion therapy to patients with ischemic stroke. The purpose of infusion therapy is:

• achieving blood thinning;
• maintaining adequate cerebral perfusion pressure (a physiological indicator characterizing the level of blood supply) not lower than 70 mm Hg. Art. to eliminate ischemia and oxygen starvation of neurons;
• correction of electrolyte disturbances, primarily high or low sodium levels in the blood.

Doctors at the Yusupov Hospital achieve a normal level of cerebral perfusion pressure in patients with ischemic stroke by increasing systemic arterial pressure and decreasing intracranial pressure. To increase blood pressure, crystalloid solutions and sympathomimetics are administered intravenously.

In case of ischemic stroke, doctors at the Yusupov Hospital maintain the patient’s circulating blood volume at the proper level and prevent the development of hypovolemia, which increases the risk of low blood pressure and reduces central perfusion pressure. These changes in the equilibrium of the internal environment of the body lead to vasodilation and increased intracranial pressure.

To maintain the overall water-electrolyte balance and ensure sufficient blood flow in the cerebral vessels, patients with ischemic stroke in the neurology clinic are administered 30-35 ml/kg/day of fluid. Patients who, upon admission to the Yusupov Hospital, have low blood pressure, elevated hematocrit, dry mucous membranes and no decompensated heart failure, are prescribed infusion therapy in a volume of 1000-1500 ml of Ringer's solution or 0.9% sodium chloride solution. Patients with developed cerebral edema are maintained in a negative water balance.

Treatment of acute ischemic stroke

In Russia, stroke ranks second in the structure of overall mortality and is the main cause of permanent disability: approximately 20% of patients who have had a stroke become severely disabled and require outside help. Among all types of stroke, ischemic brain damage predominates.

Ischemic stroke is a heterogeneous clinical syndrome. According to the international TOAST criteria, several pathogenetic variants of ischemic stroke are distinguished: stroke associated with damage to large arteries and developing as atherothrombosis or arterio-arterial embolism; cardioembolic stroke; microvascular (lacunar) stroke; rare forms (moya-moya syndrome, stroke due to inflammation of the vessel wall (vasculitis), dissection (dissection) of the arterial wall, etc.), as well as undifferentiated forms. Treatment and secondary prevention of ischemic stroke should be carried out taking into account its pathogenetic variant.

In the early 1990s. It has been shown that the development of infarction in the first minutes and hours of the disease occurs through rapid mechanisms of necrotic cell death. The trigger point is an energy deficiency, which initiates the so-called glutamate-calcium cascade, characterized by excessive release of excitatory aminacidergic neurotransmitters - aspartate and glutamate - and excessive intracellular accumulation of Ca2+ ions - the main trigger of the final mechanisms of the cascade, leading to cell death.

The formation of the nuclear zone (“core” of the infarction) is completed within 5–8 minutes from the moment of acute cerebrovascular accident. This area of ​​the brain is surrounded by a potentially viable zone of the “ischemic penumbra” (penumbra), in which the level of blood flow is reduced, but energy metabolism is generally preserved and functional, but not structural, changes are present.

The formation of 50% of the total volume of the infarction occurs within the first 90 minutes from the moment of stroke development, 70-80% - within 360 minutes, and therefore the first 3-6 hours of the disease are called the “therapeutic window”, within which therapeutic measures can be taken most effective by saving the penumbra zone.

At the same time, the processes that began in the first hours of the disease retain their significance at a later date, especially when the area of ​​ischemic damage is extensive. They induce and support other “long-term consequences of ischemia”: a genome reaction with the inclusion of genetically programmed molecular programs, dysfunction of the astrocytic and microglial cell pools with the development of immune changes and local inflammation at the site of ischemia, disruption of microcirculation and the blood-brain barrier. The time for “additional formation” of infarct changes in each case is individual and ranges from 3 to 7 days from the moment of cerebrovascular accident.

Therefore, in case of a stroke, it is very important to provide quick and pathogenetically based medical care, preferably within the first 2–3 hours from the moment of its development.

Modern understanding of the mechanisms of development of ischemic stroke has made it possible to identify two main directions of pathogenetic therapy: improving the perfusion of brain tissue (early recanalization of the vessel and reperfusion) and neuroprotective therapy.

When adequate perfusion of brain tissue is restored, clinical improvement in patients can be expected even if they do not have a visualized zone of diffusion-perfusion mismatch on MRI.

Carrying out therapeutic reperfusion is advisable within 3–6 hours, then its use significantly increases the risk of not only reperfusion damage, but also hemorrhagic complications. Thus, reperfusion should be early, active and short-term if possible.

The nature of reperfusion therapy is determined by the pathogenetic variant of stroke development. In case of occlusion of medium- and large-caliber arteries, the effectiveness of therapeutic measures is determined by the achievement of early recanalization of the vessel. With partial restoration of blood flow, such a “dramatic” improvement occurs in almost half of the patients, while in patients with no early recanalization of the affected vessel, significant clinical improvement does not occur within the first 24 hours. Moreover, in the long-term period, 3 months after a stroke, a significantly more complete restoration of impaired neurological functions is observed in patients with complete early recanalization of the occluded artery and rapid (within the first 24 hours) regression of focal symptoms.

It has been established that the severity of positive clinical dynamics depends on the speed of thrombus lysis: the best restoration of neurological functions occurs with rapid (almost instantaneous) thrombus lysis. At the same time, the rate of thrombus lysis varies with different pathogenetic variants of stroke. The most rapid and complete lysis occurs in cardioembolic stroke, which is accompanied by a significant improvement in stroke outcome and more complete functional recovery of the patient. Slow recanalization is more often observed with atherothrombotic artery disease and may not be accompanied by a significant improvement in clinical dynamics.

Spontaneous recanalization of an occluded artery occurs in approximately 10% of patients with ischemic stroke. Carrying out early ultrasound examination (transcranial ultrasound Dopplerography - devices Angiodin 3, Companion III, Sonovit SV-30, Biomed-2, Sonomed-500) increases the frequency of possible recanalization to 20%.

For most occlusions of medium and large arteries, the treatment of choice is thrombolysis, which provides early recanalization in 30-40% of cases. Currently, five generations of thrombolytics have been developed:

I generation - systemic thrombolytics: natural plasminogen activators (streptokinase, urokinase);

II generation - fibrinoselective thrombolytics: recombinant tissue plasminogen activator (rt-PA, alteplase, actylyse), recombinant prourokinase;

III generation - improved rt-PA and other plasminogen activators: fibrin-specific form of rt-PA - tenecteplase, non-glycosylated form of rt-PA - reteplase, rt-PA with a long half-life - lanoteplase, acylated streptokinase + plasminogen complex, ensuring targeted delivery to thrombus, fibrin-activated human plasminogen;

IV generation - improved plasminogen activators of the III generation (biosynthetic);

V generation - compositions of thrombolytics (rt-PA + + urokinase-plasminogen conjugate, etc.).

First generation thrombolytics are not used in clinical settings due to their systemic effect on hemostasis and the high incidence of hemorrhagic complications. Thrombolytics of III–V generations are still being tested in experimental preclinical work.

The main role in clinical practice is played by second generation thrombolytics: rt-PA and recombinant prourokinase, which have a low systemic thrombolytic effect, act predominantly on fresh thrombus and do not activate blood coagulation factors V and VII, which significantly reduces the risk of developing generalized hemorrhagic complications.

Recombinant tissue plasminogen activator is recommended for use in the first 180 minutes after the development of ischemic stroke caused by occlusion of an artery of medium and large diameter, in the absence of a hemorrhagic component in the ischemic focus and an area of ​​extensive hypodensity on CT/MRI of the brain, exceeding 1/3 of the area of ​​the middle cerebral artery , with systemic blood pressure values ​​not higher than 180/110 mm Hg. Art. A dose of 0.9 mcg/kg should be used, maximum 90 mg/day; 10% of the dose is administered intravenously as a bolus, the remaining 90% is administered intravenously by drip over 60 minutes.

The use of recombinant prourokinase is accompanied by vessel recanalization in 40% of cases, but causes hemorrhagic complications in 10.2% of patients. The use of the drug is advisable for angiographically confirmed occlusion of a large artery (internal carotid, middle cerebral, main). Recombinant prourokinase is used intraarterially, accompanied by low doses of intravenous heparin. An improvement in the outcome of the disease is recorded within 3 months of observation, even with the administration of the drug delayed by 6 hours from the onset of acute ischemic stroke. This suggests that thrombolytic therapy may be effective beyond the three-hour window if patients are carefully selected.

One of the promising areas of recanalization is surgical removal of the thrombus - endovascular extraction or excision. The results of the completed Merci Retriever Study, evaluating the effectiveness of endovascular thrombus extraction using Concentric Medical Inc. technologies, showed that rapid (instant) recanalization of an occluded vessel occurs in 48% of cases, and recanalization within the first day in 81% of cases. No complications arising from the manipulation were identified.

Contraindications to early recanalization of an occluded artery are: late admission to the hospital (outside the “therapeutic window”); absence of occlusion of medium and large diameter confirmed by transcranial Dopplerography (hemodynamic, lacunar and other pathogenetic variants of stroke); hemorrhagic syndrome of any localization and etiology observed in the patient in the last 3 months before the stroke; tumors, injuries; surgeries undergone in the last 6 weeks before the stroke; treatment-resistant arterial hypertension with blood pressure above 180/110 mmHg. Art.

Theoretical data suggested that anticoagulants, in particular heparin, should be effective in ischemic stroke. However, international studies (International Stroke Trial Collaborative Group) have shown that when treating patients with ischemic stroke with heparin, the high risk of early hemorrhage exceeds the positive effect of therapy. Only a post-hoc subgroup analysis proved the feasibility of using anticoagulant therapy with heparin in the first days of progressive atherothrombotic stroke, as well as in cases of confirmed cardiogenic embolism and surgical interventions on cerebral vessels. Heparin is prescribed during the first 3–5 days of the disease in a daily dose of up to 10–15 thousand units. under the control of laboratory parameters, primarily APTT (which should not increase more than 2 times). 1–2 days before the end of the course of heparin treatment, it is advisable to gradually reduce its dose with the prescription of indirect anticoagulants (acenocoumarol, warfarin, ethyl biscoumacetate), which continue to be taken for the next 2–3 weeks. The most effective use of warfarin is at a dose of 2–5 mg/day, especially with long-term previous heparin therapy, in the presence of atrial fibrillation, after heart valve replacement or concomitant myocardial infarction. In the absence of concomitant cardiac pathology, it is possible to prescribe phenyline in a daily dose of 0.03–0.06 g. It should be remembered that treatment with indirect anticoagulants must also be carried out under strict laboratory monitoring of coagulogram parameters. The biological activity of heparin depends on the plasma protease inhibitor antithrombin-3. Therefore, in case of antithrombin-3 deficiency, patients with increasing thrombosis of the main or internal carotid artery are recommended to administer blood plasma (albumin, dextran - 100 ml 1-2 times a day) simultaneously with heparin.

Among the non-hemorrhagic complications of heparin therapy, transient thrombocytopenia should be noted (in 25% of patients, with 5% severe), as well as paradoxical thromboembolism (Reilly et al., 2001), due to heparin-induced platelet aggregation. Thromboembolic complications caused by the use of heparin are treated by stopping its administration and prescribing indirect anticoagulants.

Thus, the administration of heparin in the first days of ischemic stroke can be recommended only for a limited number of patients. However, it has now been shown that, in contrast to conventional heparin, low molecular weight heparins (LMWHs) with a molecular weight of 4000–5000 daltons (enoxaparin (Clexane), fraxiparin, fragmin, clevarin, etc.) have predominantly anti-factor Xa activity, and inhibit even those factor Xa molecules that have managed to contact the surface of platelets. The advantages of LMWH are also: less binding to the vascular endothelium and plasma proteins, which leads to better digestibility of these drugs and their rapid absorption from subcutaneous fat depots (after subcutaneous administration, 90% of LMWH is “absorbed” and only 15–30% of conventional heparin); a longer half-life (possibly their subcutaneous administration 1-2 times a day and less frequent laboratory monitoring); lower affinity for von Willebrand factor, which helps to reduce the effect of these heparins on the cellular component of hemostasis (platelets) and significantly reduce the risk of developing “heparin thrombocytopenia/thrombosis”, and also makes it possible to better predict anticoagulant effects even when using high doses of drugs. Hemorrhagic complications with the use of LMWH are generally rarer and less severe than with treatment with conventional heparin. It is important that these drugs prevent the risk of developing deep vein thrombosis and pulmonary embolism - one of the most dangerous complications of the acute period of stroke.

Hemodilution and antiplatelet therapy, without having a radical reperfusion effect, somewhat improve microcirculation in brain tissue, which serves as the basis for their traditional use in the first days of ischemic stroke under the control of hemorheological and cardiovascular parameters.

Hemodilution is carried out with low molecular weight dextrans (reopoliglucin, reomacrodex, longasteril, reochem - 250-500 ml intravenously). The main benchmark for the effectiveness of hemodilution is to reduce the hematocrit level to 30-35%.

A comparative comparison of the effects of various antiplatelet drugs showed the high effectiveness of acetylsalicylic acid (thrombo ACC, aspirin cardio) at a dose of 1 mg/kg/day in the absence of a sufficient antiaggregation effect of smaller doses of the drug, which is associated with their insufficient effect on cAMP and prostacyclin concentration. The effectiveness of pentoxifylline (trental, flexital, pentilin), which has a complex rheological effect aimed not only at reducing the aggregation ability of platelets, but also at improving the deformability of erythrocyte membranes and normalizing microcirculation in general, has also been established. In young patients with a hyperkinetic type of blood circulation (severe tachycardia, persistent increase in systolic blood pressure), it is preferable to choose small doses of β-blockers (obzidan, anaprilin, inderal), which have antiaggregation properties. In elderly patients, it is advisable to prescribe angioprotectors (anginin, prodectin, parmidin), which also have an antiplatelet effect.

Drugs with complex vascular-metabolic action, a prominent example of which is Cavinton (vinpocetine), have a positive effect on the state of cerebral hemodynamics. An analysis of 25 years of experience in using the drug has shown that Cavinton improves cerebral blood flow and microcirculation, exerting a selective vasodilating and antivasoconstrictor effect on cerebral vessels, inhibiting aggregation and adhesion of blood cells, and normalizing the deformability of erythrocyte membranes. Along with this, the drug helps improve energy metabolism, optimizing redox processes, activating the transport of oxygen and glucose, as well as their utilization in brain tissue. Cavinton has antioxidant and anti-excitotoxic properties, normalizes the ionic gradient of cell membranes. For ischemic stroke in the acute phase, it is effective to prescribe the drug at a dose of 10–20 mg/day intravenously (diluted in 500 ml of physiological solution) for 7–10 days (in some cases up to 21 days) with the subsequent transfer of the patient to tablet forms drug: Cavinton forte - 10 mg 3 times a day for 3-4 weeks, then Cavinton - 5 mg 3 times a day for 1-3 months.

Active reperfusion therapy is possible only in a hospital after a neuroimaging study (CT/MRI of the brain), which allows to exclude the hemorrhagic component of the lesion, assess the size of the ischemic area and the pathogenetic variant of the stroke. This highlights the advantages of another direction of therapy - neuroprotection (cytoprotection, metabolic protection of the brain), which can be used at the prehospital stage when the first symptoms of a stroke appear, even if it is possibly hemorrhagic.

Primary neuroprotection is aimed at interrupting the rapid mechanisms of necrotic cell death - reactions of the glutamate-calcium cascade. The use of this type of neuroprotection should begin from the first minutes of ischemia and continue treatment throughout the first 3 days of stroke, especially active in the first 12 hours. Secondary neuroprotection is aimed at reducing the severity of “long-term consequences of ischemia,” i.e., blocking proinflammatory cytokines, cellular molecules adhesion, inhibition of pro-oxidant enzymes, increased trophic supply, temporary inhibition of apoptosis. It can be started 3–6 hours after the onset of stroke and should continue for at least 7 days.

The discovery of the phenomenon of excitotoxicity resulted in the creation of new therapeutic strategies—drugs antagonists of glutamate NMDA and AMPA receptors and inhibitors of presynaptic glutamate release. Despite the fact that drugs from these groups experimentally demonstrated pronounced neuroprotective effects, clinical trials of most of them were discontinued due to a wide range of serious side effects (mental, locomotor, general toxic).

Currently, studies are ongoing on the effectiveness of remacemide, a low-affinity non-competitive antagonist of NMDA receptors that has the ability to inhibit voltage-gated calcium channels. In clinical trials of intravenous and oral forms of remacemide at a dose of up to 400 mg every 12 hours, no significant side effects were found.

Another drug that blocks NMDA-gated channels in a voltage-dependent manner is magnesium sulfate.

The attention of researchers is drawn to the role of the inhibitory neurotransmitter glycine in the mechanisms of acute cerebral ischemia. The role of glycine as an inhibitory neurotransmitter has been proven in almost all parts of the central nervous system. G. E. Fagg and A. C. Foster, F. Mayor et al. concluded that GABA and glycine are equivalent neurotransmitters that provide protective inhibition in the central nervous system, the role of which increases under conditions of increased glutamate release. Glycine exhibits its inhibitory properties through interaction not only with its own glycine receptors, but also with GABA receptors.

At the same time, JW Johnson and P. Ascher (1987) were the first to experimentally prove that glycine in submicromolecular concentrations is necessary for the normal functioning of glutamate NMDA receptors. The potentiating effect of glycine on NMDA receptors occurs at concentrations below 0.1 µM, and concentrations from 10 to 100 µM completely saturate the glycine site. Administration of high concentrations of glycine (100 µmol and 1 mlmol) to rats under conditions of oxygen deprivation did not cause long-term modulation of NMDA receptor activity in the hippocampus and did not increase excitotoxicity. Interestingly, administering high doses of glycine or some of its agonists to animals (1-amino-1-carboxycyclopropane, which is an almost complete agonist, and D-cycloserine, which has 40–60% of the effectiveness of glycine) has an anticonvulsant effect and also enhances the effects of antiepileptic drugs.

Along with the neurotransmitter, glycine also has a general metabolic effect and binds low molecular weight toxic products that are formed in large quantities during ischemia.

Being a natural brain metabolite, glycine does not exhibit toxicity even in doses of more than 10 g/day. The only side effect of the drug can be considered mild sedation. The use of glycine in a dose of 1–2 g/day for 5 days in patients with acute ischemic stroke (starting 6 hours after the development of the first symptoms) allows for anti-ischemic protection of the brain in patients with different locations of vascular lesions and different severity of the condition - it significantly accelerates regression neurological symptoms (p < 0.01), improves functional recovery of patients and reduces 30-day mortality compared to the placebo group. A significant reduction in the volume of cerebral infarction and inhibition of subsequent cystic transformation of the lesion with the use of glycine, as well as accelerated normalization of the electroencephalographic pattern, have been proven.

An important area of ​​secondary neuroprotection is antioxidant therapy. In the 1980s It was found that in the very early period of acute focal cerebral ischemia it is advisable to use “traps” of free radicals and drugs that destroy peroxides (with sulfide and thiol groups): 2,3-dimercaptopropanesulfonate (unithiol, antaxone, dimercaprol, dicaptol, dithioglycerol), thiosulfate sodium, etc. Following this, the administration of tocopherols and carotenoids, which bind catalysts and inactivate singlet oxygen, was recommended. However, attempts to use unithiol and tocopherol (vitamin E, including in a combined form - aevit) in the complex of intensive therapy for ischemic stroke showed the insignificance of the “contribution” of these drugs to the overall result of treatment.

Currently, potential neuroprotectors used in cerebral ischemia also include the enzymes superoxide dismutase (SOD) and catalase, glutathione, lazaroids, iron chelates, and phenyl-t-butyl-nitrone. Experimental and clinical trials of selective blockers of neuronal NO synthase [7-nitroindazole and 1-(2-fluoromethylphenyl)-imidazole], which significantly reduced the size of the infarct zone after focal and global cerebral ischemia in animals, are ongoing. Relatively selective blockade of iNO synthase with aminoguanidines also had a powerful neuroprotective effect in experimental stroke. Aminoguanidines have protective properties even when treatment is delayed by 24 hours, which is of obvious interest in terms of their possible clinical use in the treatment of ischemic stroke.

Of great interest is the organoselenium compound ebselen, which has glutathione peroxidase-like activity. Ebselen is able to suppress oxidative stress and inflammatory reactions, inhibiting the mitochondrial component of apoptosis, the induction of which is associated with the release of cytochrome C.

Unlike many other organoselenium compounds, ebselen has low toxicity.

In the course of experimental and clinical studies, the domestic drug Mexidol showed high efficiency. When administered intravenously at a dose of 100 to 1000 mg/day, Mexidol has a pronounced antioxidant effect, increasing the activity of the endogenous antioxidant system and reducing the severity of free radical processes.

The domestic drug emoxypine, a derivative of 3-hydroxypyridine, has an antioxidant effect. The main effects of emoxypine are inhibition of lipid peroxidation and activation of the antioxidant system, changes in the activity of membrane-bound enzymes and modification of the metabolic, receptor and transport functions of cell membranes. The drug is safe and well tolerated by patients.

An important area of ​​neuroprotective therapy is the use of drugs with neurotrophic and neuromodulatory properties.

Endogenous regulators of CNS functions—neuropeptides—play a very important role. Their molecules, which are short amino acid chains, are “cut” from larger protein precursor molecules by proteolysis enzymes (“processing”) only “in the right place and at the right time,” depending on the needs of the body. Neuropeptides last only a few seconds, but their duration of action can be measured in hours. Each of the regulatory peptides is capable of inducing or inhibiting the release of a number of other peptides. As a result, the primary effects of a particular peptide can develop over time in the form of chain and cascade processes.

The physiological activity of neuropeptides is many times greater than that of non-peptide compounds. Depending on the site of their release, neuropeptides can perform a mediator function (signal transmission from one cell to another), modulate the reactivity of certain groups of neurons, stimulate or inhibit the release of hormones, regulate tissue metabolism or function as effector physiologically active agents (vasomotor, Na+-uretic and other types of regulation). It is known that neuropeptides are able to regulate the activity of pro- and anti-inflammatory cytokines through modulation of the activity of their receptors. Many neuropeptides exhibit pronounced neurotrophic growth properties and easily penetrate the blood-brain barrier.

One of the most well-known drugs of the neurotrophic series is Cerebrolysin - a protein hydrolyzate of an extract from the brain of pigs, the active effect of which is due to the fraction of low molecular weight peptides. The drug optimizes brain energy metabolism and calcium homeostasis, stimulates intracellular protein synthesis, slows down the processes of the glutamate-calcium cascade and lipid peroxidation. The optimal daily dose for moderate ischemic stroke is 10 ml, for severe strokes - 20 ml intravenously for 7-10 days of illness (further continuation of the course in the form of intramuscular injections of 5 ml per day until 21 days of illness is possible). In the acute period of carotid ischemic stroke, doses of 30–50 ml are more effective compared to 10–20 ml.

According to our data, the use of Cerebrolysin in patients with ischemic stroke in the carotid system at a dose of 50 ml/day intravenously significantly inhibits the growth of the infarction zone (by the 3rd day of the disease), and also normalizes the electroencephalographic pattern, compared with a dose of 10 ml .

At the Research Institute of Molecular Genetics of the Russian Academy of Sciences, a synthetic analogue of the ACTH fragment was created - the drug Semax, which is a heptapeptide devoid of hormonal activity. Semax is the first Russian non-depleting nootropic drug from the group of neuropeptides, which has a number of important advantages over well-known analogues: complete absence of toxic and side effects, hormonal activity, an increase in the duration of action by more than 24 times compared to the natural analogue, the possibility of intranasal administration with real penetration into the brain.

According to the results of a randomized, double-blind, placebo-controlled study conducted at the neurological clinic of the Russian State Medical University, the use of the drug in daily doses of 12-18 mcg/kg for 5 days leads to a significant reduction in 30-day mortality and improved clinical outcome and functional recovery of patients with ischemic heart disease. stroke initially of varying severity.

The use of drugs that affect energy metabolism and redox processes in nervous tissue does not go unnoticed. It has been established that the use of antihypoxants (short-acting barbiturates, benzodiazepines) is advisable only for the most severe forms of ischemic strokes.

For limited cortical foci of ischemia, clinically manifested by disorders of higher mental functions (primarily speech) and moderate motor deficits, the administration of nootropic drugs (GABA derivatives) that activate energy metabolism and redox processes in the brain is effective. A study of the dose-dependent effectiveness of piracetam (nootropil, lucetam, memotropil) showed that the optimal doses of the drug in the first 10–15 days of ischemic stroke range from 6 to 12 g/day when administered intravenously. To achieve the maximum clinical effect, long-term use of the drug is recommended (from the 15th day - oral administration at a dose of 4.8 g / day for 1-1.5 months), given the delayed neurotransmitter effect of piracetam, which increases the plasticity of nervous tissue.

Starting from the first days of the disease, after the formation of morphological infarct changes in the brain, reparative therapy aimed at improving the plasticity of healthy tissue surrounding the infarction, activating the formation of polysynaptic connections, and increasing the density of receptors is becoming increasingly important. Secondary neuroprotectors with trophic and modulatory properties, as well as nootropics (GABA derivatives), choline derivatives (gliatilin) ​​enhance regenerative and reparative processes, helping to restore impaired functions.

Gliatilin (a-glycerylphosphorylcholine) is a compound containing 40% choline and is converted in the body into the metabolically active form of phosphorylcholine, capable of penetrating the blood-brain barrier and activating acetylcholine biosynthesis in the presynaptic membranes of cholinergic neurons. Pilot clinical studies of gliatilin in the acute period of ischemic stroke (intravenous administration at a dose of 1 g 3–4 times a day for 5 days) revealed a beneficial effect of the drug on clinical dynamics, especially on the mental activity of patients, memory, and restoration of speech functions.

A study of the effectiveness of the domestic drug aplegin (carnitine chloride) in the acute period of carotid ischemic stroke showed that its administration at a daily dose of 7–15 mg/kg during the first 7–10 days of the disease significantly improves the clinical course and outcome of the stroke. The drug has an “awakening” effect in seriously ill patients, accelerating the regression of focal neurological symptoms and mental dysfunction.

It is important to note that the treatment of acute ischemic stroke also includes components of its secondary prevention. Secondary prevention becomes especially relevant from the second week of the disease, when the risk of repeated vascular episodes increases significantly. The most significant preventive measures include monitoring blood pressure, glucose and blood lipids with correction of identified changes. In recent years, the importance of using antihypertensive drugs from the group of ACE inhibitors (captopril, enalapril, quinapril, lisinopril, moexipril, perindopril, ramipril, cilazapril, fosinopril) has been proven not only in patients suffering from severe arterial hypertension, but also in people with borderline and even normal hypertension. blood pressure values. This is due to the “additional” effects of ACE inhibitors - their normalizing effect on the structure and functional state of the vascular wall of arteries of different sizes (from the main arteries of the head to arterioles). The most important and proven area of ​​secondary prevention is the long-term (often lifelong) use of true antiplatelet agents: acetylsalicylic acid (including in combination with dipyridamole (Curantil, Persantine)), clopidogrel (Plavix), ticlopidine (Aklotin, Tagren, Tiklid), high doses of dipyridamole. At the same time, in patients who have suffered a cardiogenic embolism against the background of atrial fibrillation, after heart valve replacement, after myocardial infarction, it is advisable to prescribe the indirect anticoagulant warfarin. In this group of patients, warfarin causes a reduction in the relative risk of recurrent stroke by 36–47% compared with aspirin, with a comparable frequency of hemorrhagic complications (1.3 and 1.0%). If hemodynamically significant stenoses of the carotid arteries are detected, as well as the presence of “embologenic” atherosclerotic plaques in them, a consultation with a vascular surgeon is necessary to decide on an endarterectomy or another method of surgical prevention of recurrent cerebrovascular accident. The presence of severe dyslipidemia, not correctable by diet, requires the prescription of lipid-lowering therapy (statins - lovastatin, simvastin, atorvastatin, pravastatin, fluvastatin, cerivastatin; fibrates - bezafibrate, fenofibrate, ciprofibrate).

Thus, improving the understanding of the causes and mechanisms of damage to brain tissue against the background of acute cerebrovascular accident determines the main strategic directions for the treatment of cerebral stroke. The results of clinical and experimental studies in recent years indicate the need for early (within the “therapeutic window”) combined pathogenetic therapy of ischemic stroke, including early recanalization of an occluded vessel and reperfusion of brain tissue, combined neuroprotection, stimulation of regenerative and reparative processes, as well as components of secondary prevention (prevention of (re-)embolism, secondary vascular and tissue damage).

The introduction of modern approaches to the treatment of ischemic stroke in the clinic of nervous diseases of the Russian State Medical University (Department of Fundamental and Clinical Neurology) made it possible to achieve significant success in the treatment of patients with ischemic stroke: reduce 30-day mortality from 32 to 10% within 5 years and increase the number of patients with good functional recovery (Barthel index >75; modified Rankin scale - 0–2) to 73.7% of the total number of surviving patients.

Increasing knowledge about ischemic brain damage and the regeneration of brain tissue allows us to more and more clearly imagine the endless complexity of understanding these processes. Fortunately, working in a clinic, we have the opportunity not to move away from the realities of life and daily evaluate the application of scientific hypotheses in practice. This helps to maintain optimism and hope.

V. I. Skvortsova , Doctor of Medical Sciences, Professor, Corresponding Member of the Russian Academy of Medical Sciences, Russian State Medical University, Moscow

Treatment of ischemic cerebral stroke with neuroprotectors

Currently, there are many drugs that have a neuroprotective effect. Doctors at the Yusupov Hospital use only neuroprotectors, the effectiveness of which has been proven by scientific research, to treat ischemic stroke. One of these drugs, which has the most versatile mechanisms of action in relation to oxidative stress (damage to brain cells as a result of oxidation) and a wide evidence base for ischemic stroke, is EMHPS (ethyl-methyl-hydroxypyridine succinate).

In this case, based on clinical experience in the use of EMGPS, the following scheme for its administration is used:

• at the prehospital stage, 400 mg is administered intravenously as a bolus once;
• in the acute period of ischemic stroke (up to 14 days), 5 mg/kg/day is administered intravenously, but more than 800 mg/day;
• during the recovery period (within 14 days), 400–800 mg of the drug 2-3 times a day is administered intramuscularly or intravenously.

One of the mechanisms of the damaging effect of ischemia is cholinergic insufficiency. With pathology of cerebral vessels, the number and size of cholinergic neurons in brain structures decreases. Neurologists at the Yusupov Hospital use the following regimen for the use of choline alfoscerate for acute ischemic stroke: for the first 3-7 days, 1000 mg is administered intravenously 2 times a day, and from the second week they switch to taking 400 mg of the drug per day 2 times a day (course of treatment - 2 month).

The combination of ethyl-methyl-hydroxypyridine succinate and choline alfoscerate in the context of ischemic stroke allows doctors at the Yusupov Hospital to fully influence the fundamental mechanisms of the development of clinical symptoms associated with ischemia and cholinergic insufficiency.

Drugs with proven effectiveness in ischemic stroke include the cerebroprotector Citicoline. Doctors at the Yusupov Hospital use it for both primary and secondary neuroprotection. Primary protection of brain cells begins from the first minutes of ischemia and continues during the first three days of stroke, especially active during the first twelve hours. Secondary neuroprotection reduces the severity of long-term consequences of ischemia. Neurologists begin it 3-6 hours after the onset of a stroke and carry it out for at least seven days.

Rehabilitation after a stroke at home

After overcoming the acute period in the hospital, a rehabilitation period begins for a pensioner with a stroke. Relatives need to decide where it is better for an elderly person to undergo a recovery course: at home or in a rehabilitation center.

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If the family has decided to independently care for the patient after a stroke, they need to follow the recommendations of the attending physician and maintain constant contact with specialized specialists: a psychologist, a neurologist, a speech therapist.

At home, a separate place is assigned to a bedridden patient after a stroke. The bed is equipped with an anti-decubitus mattress. A small table is placed nearby, on which essential items are placed: a bottle of water, care products, a table lamp.

Specialists can come to the home 1-2 times a week, work with the patient and teach home methods of conducting developmental activities. The rest of the time, family members carry out the recommended exercises with the pensioner for 10-20 minutes several times a day. During weekly visits, specialists monitor the dynamics of changes, make additions and adjustments.

Motor abilities are restored using a complex of therapeutic exercises. Before performing the exercises, it is advisable for the patient to take a shower or bath to warm up the body. If there are contraindications to taking a bath or other difficulties, the affected areas are warmed with a heating pad. The muscles will be more flexible and there will be no pain.

Examples of gymnastic exercises:

• pulling up while lying on your back, holding the headboard of the bed;
• eye movements left and right, up and down with closed and open eyelids;
• alternately raising the right and left arms and legs;
• bending the knee and grabbing the shin with the hand;
• joint movements of healthy and motionless limbs to the right and left with a rubber ring put on them.

When carrying out therapeutic exercises, the pensioner’s condition is closely monitored. He shouldn't get tired. If such signs are observed, it means that the amount of stress does not correspond to the physical strength of the patient. We need to make an adjustment: reduce the pace and number of exercises.

Speech is restored by memorizing poetry and tongue twisters. At the initial stage, simple children's poems are chosen, which are easier for a pensioner to recite after a stroke. Gradually more complex material is selected.

Looking at family photographs can activate the process of remembering, since it is easier for the patient to recall the past in his memory. An elderly person remembers acquaintances and friends in the images, then the events associated with them. He tries to pronounce the names of the places he has visited, the objects he sees in the images.

Scientists believe that singing has a beneficial effect on people who have suffered a stroke. If they hear singing, sing together with loved ones, speech activity will be restored faster.

For rehabilitation to be successful, an elderly person should not be in a social “vacuum”: you constantly need to communicate with him, talk, ask questions, even if at first he cannot answer them. In this way, the patient’s desire to speak is stimulated, he remembers words and their meaning.

Chess, checkers, and dominoes are used to develop thinking abilities. In a family, even a small child can take part in restoring the health of a grandfather or grandmother by putting together puzzles, mosaics, or playing a board game.

A separate issue is the organization of nutrition for an elderly person after a stroke.

Excluded from use:

• alcoholic drinks;
• fatty and spicy foods;
• coffee, strong tea;
• sweets.

It is advisable to add to the diet:

• drink liquid of at least 1.5 liters. per day;
• increase consumption of fruits and vegetables;
• eat whole grains;
• replace sweets with dried fruits.

Food should consist of useful substances and be easily digestible so that the body is not overloaded.

It is useful to cook boiled vegetables, dishes from lean fish and meat, and porridge with low-fat milk. If there are paresis and problems with swallowing, the patient is fed through a tube with ready-made nutritional mixtures. As soon as the opportunity arises, you need to take the patient for a walk. Staying in the fresh air is good for brain activity, the body receives oxygen and vitamin D, and appetite appears.

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The moral atmosphere in the house is of great importance. Patients who receive family support recover faster. If they experience hostility from others or rudeness, the healing process is slowed down. There is no need to criticize and laugh at clumsiness and awkwardness. Only with encouragement will an elderly person develop a strong desire to overcome the disease.

Drugs after ischemic cerebral stroke

In order to prevent recurrent acute cerebrovascular accident. Doctors at the Yusupov Hospital prescribe antihypertensive drugs to patients who have suffered an ischemic stroke. During your stay at the neurology clinic, cardiologists individually select the most effective drug and its dose. In some cases, it is recommended to take combination antihypertensive drugs.

If there is a depressive state, antidepressants are prescribed. They not only eliminate the patient’s feeling of fear, but also eliminate the negative symptoms that develop as a result of cerebrovascular accidents. If the patient has no contraindications, he is prescribed antiplatelet agents. These include:

• acetylsalicylic acid and its derivatives (Trombo-AS, Aspirin Cardio, Acecardol, Cardiomagnyl, Aspicor, CardiASK);
• ADP receptor blockers (Clopidogrel, Ticlopidine);
• phosphodiesterase inhibitors (Triflusal, Dipyridamole);
• glycoprotein receptor blockers (Lamifiban, Eptifibatide, Tirofiban, Abciximab);
• inhibitors of arachidonic acid metabolism (Indobufen, Picotamide);
• medicines based on the Ginkgo Biloba plant (Bilobil, Ginos, Ginkyo).

Some plants also have an antiplatelet effect: horse chestnut, blueberries, green tea, ginger, garlic. Vitamin E also falls into this category.

In order to receive treatment and rehabilitation after an ischemic stroke with modern drugs, call us by phone. You will make an appointment with a neurologist, who, after the examination, will select an individual treatment regimen. The collective decision on the choice of treatment method for the most severe patients with ischemic stroke is made by doctors of the highest category, candidates and doctors of medical sciences on an expert council.

"Trombital" is a drug for the prevention* of heart attacks and strokes with a special composition

As an advertisement

Key Features

Combined composition:

• Acetylsalicylic acid prevents the formation of blood clots by disrupting platelet aggregation and prothrombin formation. • Magnesium hydroxide protects the gastrointestinal mucosa from acid attack.

Individual approach: the presence of two dosages provides a choice depending on the patient’s needs.

• "Trombital" containing acetylsalicylic acid in a dose of 75 mg + magnesium hydroxide 15.20 mg for the prevention of vascular damage to the heart and brain in patients with risk factors (for example, diabetes mellitus, hyperlipidemia, arterial hypertension, obesity, smoking, old age)
• "Trombital FORTE" with double content of active ingredients (acetylsalicylic acid 150 mg + magnesium hydroxide 30.39 mg) to prevent recurrences in patients who already have a history of heart attack or stroke.

It has been proven that the use of acetylsalicylic acid in patients at risk for the purpose of primary prevention reduces the incidence2,3:

• myocardial infarction by 36%
• ischemic stroke by 24%

It has been proven that the use of acetylsalicylic acid in patients with heart and vascular diseases reduces the risk4-6:

• myocardial infarction 4 times
• stroke 2.5 times
• mortality from CVDs 8 times

Favorable safety profile: the presence of magnesium hydroxide in Trombital sets it apart from monopreparations of acetylsalicylic acid. It has been proven that the combination of acetylsalicylic acid and magnesium hydroxide reduces the risk of side effects by 9 times7 compared with the use of the usual form of ASA.

Interesting facts about ASC:

Acetylsalicylic acid (ASA) in doses of 75–150 mg is one of the most well-known substances used in the prevention and treatment of cardiovascular diseases. It is also widely used in combination therapy with antiplatelet agents, statins, etc. However, long-term use of ASA, and this is the mode in which it is usually prescribed, often causes the development of gastric or duodenal ulcer8. Given these limitations, the combination of ASA and magnesium hydroxide has a higher safety profile8. This is an antacid that adsorbs hydrochloric acid and reduces the activity of gastric juice8. It has enveloping properties and protects against negative effects on the gastric mucosa8.

An important addition about the drug "Trombital" is:

• Affordable cost1 – “Trombital” is an affordable drug for people who are sensitive to price.
• A simple dosage regimen: only 1 tablet per day - easy to remember.
• Better tolerability and a more favorable safety profile compared to monopreparations of acetylsalicylic acid.9
• Convenient use: the tablet can be swallowed whole, chewed or crushed, this is especially important for older people who may have difficulty swallowing.

Links:

*If there are risk factors. SM IMP Trombital and Trombital Forte

1. DSM, September 2021, category Antiplatelet agents, tablets.

2. Ridker P.M. et al. Randomized trial of low-dose aspirin in the primary prevention of CVD in women. New England Journal of Medicine. 2005 Mar 31;352(13):1293-304.

3. Hanson I. et al. Effect of rapid blood pressure lowering and low-dose aspirin in patients with hypertension: main results of the randomized Optimal Treatment of Hypertension trial. Lancet. 1998; 351:1755–1762

4. Theroux P. et al. Aspirin, heparin and their combination in the treatment of acute unstable angina. New England Journal of Medicine. 1988 Oct 27;319(17):1105-11.

5. Fields V.S. et al. A controlled study of aspirin in cerebral ischemia. Stroke. 1977 May-Jun;8(3):301-14.

6. Kubota N. et al. Statin and aspirin therapy improves long-term outcomes of percutaneous coronary intervention. Heart and blood vessels. 2008 Jan;23(1):35-9.

7. Consilium Medicum, Vorobyova N.M., 2014, volume 16, No. 10

8. Kadykov A.S., Shakhparonova N.V. Modern prevention of primary and recurrent ischemic strokes. The role of antiplatelet therapy // Breast Cancer. 2013. No. 30. pp. 1603–1606.

9. Bulakhova E.Yu., Korennova O.Yu., Kozyreva V.A., Kurochkina S.D. Comparative assessment of the tolerability and safety of acetylsalicylic acid drugs in patients with coronary heart disease // Arterial hypertension, 2009. No. 4. pp. 493–496.

There are contraindications.
It is necessary to consult a specialist. Related product: [product](Trombital)

How to prevent a stroke?

05.08.2019

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Companion
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Scientist Dmitry Napalkov: seven rules help prevent stroke

Dmitry Napalkov, professor of the department of faculty therapy No. 1 of the medical faculty of the First Moscow State Medical University named after I.M. Sechenov, spoke to the Sobesednik publication about measures to prevent stroke

Every year, about 12 million cases of stroke are recorded worldwide. In Russia, someone has a stroke every minute and a half. This insidious disease can happen to anyone, regardless of age or genetics. When this happens to a loved one or an acquaintance, we grab our heads: well, surely everything could have been prevented? Can! Only for this you need to comply with several important conditions. One of my friends had a stroke while he was on a business trip. I worked all day long without rest. I had a sharp headache, my mind was so clouded that I couldn’t even speak two sentences. Colleagues did not immediately call an ambulance. They gave me some kind of pill: “Just lie down, everything will pass.” After a couple of hours, the situation worsened so much that only intensive care was able to pump out my friend.

Doctor of Medical Sciences, Professor of the Department of Faculty Therapy No. 1 of the Faculty of Medicine of the First Moscow State Medical University named after I.M. Sechenov Dmitry Napalkov to our question - how to prevent a stroke? – answered this:

– Everyone wants to prevent themselves from having a stroke, but few people do anything about it. Cardiovascular diseases depend mainly on lifestyle. Lack of physical activity, unhealthy diet, and bad habits are very serious risk factors. However, with serious disturbances in the functioning of the heart and blood vessels, nutrition and exercise alone will not help. You must take medications as prescribed by your doctor. And be very careful! For example, a well-known anticoagulant (vitamin K antagonist), used to prevent stroke, imposes severe dietary restrictions: raspberries, green tea, green vegetables, cabbage, eggs and other foods rich in vitamin K are undesirable. However, science does not stand still, and a new generation of drugs has now been created - for example, based on direct thrombin inhibitors. They do not require dietary restrictions.

Do not neglect measures such as: reducing the amount of salt in the diet to 5 g per day (about half a teaspoon), avoiding foods high in cholesterol. Add fruits, vegetables, whole grains and low-fat dairy products to your daily diet, as well as one serving of fish two to three times a week. See a specialist regularly. It is important to consult not only a therapist, but also a neurologist. It is necessary to do an ultrasound of the neck vessels and receive a health card.

Monitor your blood pressure. Arterial hypertension increases the risk of stroke several times. Therefore, it is advisable to measure your blood pressure levels at least once a week. Even if you feel well and do not have symptoms of hypertension such as headaches, fatigue and sleep disturbances, an increase in resting pressure readings above 140/90 mm Hg. Art. – this is already a reason to see a doctor.

World practice shows that by controlling blood pressure alone, it is possible to reduce the risk of stroke by 50%.

Control your weight. Neurologists agree that weight loss is one of the most effective measures in preventing stroke. Excess body weight contributes to the development of high blood pressure, diabetes and puts increased strain on the heart muscle.

It is clear that we cannot reduce our weight without a proper diet. It is worth giving up fatty and heavy foods to reduce blood sugar and cholesterol levels. To get results, you must stick to the diet for at least 3-4 months.

Be active. Physical inactivity, or too low a level of physical activity, is the scourge of our time. Therefore, it is important to do physical exercise for more than 30 minutes at least 5 times a week.

Aerobic exercise is the best way to prevent stroke—repetitive exercise that increases the supply of oxygen to the body. Your doctor will choose the best exercise for you, taking into account your age and existing diseases.

Well, these rules are available to everyone: use the stairs instead of the elevator, better get off one stop early and walk, find time to walk during your lunch break.

Treat diabetes. Those who suffer from diabetes have a significantly increased risk of stroke. Patients with diabetes suffer strokes much more severely than others. This is because due to atherosclerosis, many arteries are unable to move oxygen. And alas, the prognosis for stroke in diabetes mellitus in most cases will be much worse.

Drink less alcohol. Until recently, the relationship between alcohol consumption and stroke remained in question, but today there is no doubt: alcohol significantly increases the risk of stroke.

Stop smoking. Smoking people have a stroke 2-3 times more often than non-smokers. Conclusion: the more you smoke, the higher your risk of stroke! In addition, the age of the smoker is of great importance: in men and women who smoke under the age of 55, smoking is the main risk factor for stroke.

Atherosclerosis develops in the damaged vascular wall (thickening of the wall and reduction of the lumen), and this increases the risk of blood clot formation in the vessels of the brain. Smoking affects the properties of special blood cells called platelets, resulting in an increased risk of blood clots in the large arteries that carry blood to the brain and heart. Smoking also increases blood pressure, which is one of the most important risk factors for stroke.

By the way! A study of thousands of patients over 35 years (Nurses' Health Study) showed that a typical European diet, including large amounts of meat, eggs, fried and salty foods, refined bread, full-fat dairy products, sweet desserts and chips, increases the risk of stroke by 58% . While eating whole grains, fruits, vegetables and fish reduces this risk by 30%.

Link to publication: /sobesednik.ru

Stroke is an acute circulatory disorder in the brain that causes damage and death of nerve cells.

The danger of a stroke lies in its unexpected and very rapid development, which in many cases ends in death, therefore, at the first signs of a stroke, emergency medical attention is required! Prompt medical attention can minimize brain damage and prevent possible complications.

Another unpleasant “surprise” that a stroke brings is the disability of the person who experienced it, because Statistics say that 70-80% of people become disabled after a stroke.

Stroke includes the following pathological conditions, or its types: cerebral hemorrhage, cerebral infarction and subarachnoid hemorrhage.

Causes of stroke

As you and I already know, dear readers, a stroke occurs as a result of a circulatory disorder in a certain area of ​​the brain. This disorder, or pathology, occurs due to blockage and rupture of a brain vessel. Let's look at what actually can provoke this circulatory disorder?

Factors that increase the likelihood of developing a stroke:

- hypertension (hypertension - high blood pressure); - stenosis of the carotid arteries; - thrombosis; - embolism; - blood clotting disorder; - cerebral aneurysms; - heart rhythm disturbances; - atherosclerosis and other cardiovascular diseases; - diabetes; — bad habits (smoking, drinking alcohol and drugs); - insomnia; - obesity; - sleep apnea - stopping breathing for more than 10 seconds; - hypothermia of the body; - injuries; - age - with increasing age, the state of health of blood vessels and heart.

Types of stroke

Ischemic stroke (cerebral infarction)

This type of stroke occurs most often - in 90% of all cases. It occurs as a result of narrowing or blocking of the arteries of the brain, due to which the blood flow in it is sharply reduced - ischemia. Due to the lack of blood flow, brain cells are deprived of nutrients and oxygen and can begin to die within just a couple of minutes.

Hemorrhagic stroke (intracerebral hematoma)

Accounts for approximately 10% of cases of the disease. A hemorrhagic stroke occurs when a blood vessel leaks or ruptures.

Transient ischemic attack (TIA) or ministroke

This type is characterized by a short-term (less than 5 minutes) episode of stroke symptoms.

In a mini-stroke, a blood clot disrupts blood flow to part of the brain, but does not cause significant damage because the blockage of the vessel is temporary.

Important! With a mini-stroke, as with a stroke, it is necessary to urgently call an ambulance, even if the symptoms have completely disappeared. Symptoms of a mini-stroke indicate that the vessels leading to the brain are partially blocked or narrowed and there is a risk of developing a stroke.

The first signs and symptoms of a stroke

Important! If symptoms of a stroke appear, call an ambulance immediately!!!

Symptoms of a stroke:

- sudden weakness; - paralysis or numbness of the muscles of the face, limbs (often on one side); - speech impairment; - blurred vision; - severe sharp headache; - dizziness; - loss of balance and coordination, gait disturbance.

How to recognize a stroke in a person?

If you notice that a person is not behaving naturally, then do not rush to think that he is drunk; perhaps the person is having a stroke. To recognize this disease, pay attention to the following points:

1. Stroke recognition technique “UZTs”:

- U - smile. During a stroke, the patient’s smile is usually crooked; the corner of the lips on one side may be directed downward rather than upward.

- S - speak. Say a simple sentence, for example: “The sun is shining outside the window.” With a stroke, pronunciation is often (but not always) impaired.

- P - raise your hands up. If your arms do not rise at the same rate, this may indicate a stroke.

1. “IMPACT” stroke recognition technique:

- U - smile. After a stroke, the smile becomes crooked and asymmetrical;

- D - movement. Raise both arms and both legs up at the same time - one of the paired limbs will rise slower and lower;

- A - articulation. Say the word “articulation” or several phrases - after a stroke, diction is impaired, speech sounds sluggish or simply strange;

- R - solution. If you find violations in at least one of the points (compared to the normal state), it’s time to make a decision and call an ambulance. Tell the dispatcher what signs of a stroke (STROKE) you have found and a special resuscitation team will arrive quickly.

If you detect signs of a stroke in a person, call an ambulance immediately!!! The faster qualified assistance is provided, the greater the chances of eliminating the consequences of this disease!!!

If you notice signs of a stroke in a person, you must:

1. Position the patient so that his head is elevated approximately 30°.
2. If the patient loses consciousness and ends up on the floor, move him to a more comfortable position.
3. If the patient has prerequisites for vomiting, turn his head to the side so that the vomit does not enter the respiratory system. If this has already happened, it is necessary to clear the airways by placing the patient on his side and clean the oral cavity.
4. Do not let the patient drink or eat food, because if he has spasms in the respiratory tract, he may suffocate.
5. Make sure the victim has fresh air available. Open a window or window to allow fresh air into the room. Remove tight clothing, unbutton your shirt collar, or loosen your tight belt or waistband.
6. If possible, measure your blood pressure and glucose levels. The recorded indicators must be recorded and reported to the arriving doctors. It should also be noted that if the pressure is high, you should not immediately lower it, because In the first hours of a stroke, increased blood pressure is a necessary norm due to adaptation of the brain. Only over time can the patient be given medication that lowers blood pressure.
7. If his pulse cannot be felt, his heart has stopped and his breathing has stopped, immediately begin chest compressions and mouth-to-mouth or mouth-to-nose artificial respiration. Everything else is the task of emergency medical services.

Consequences of a stroke

Each person experiences the effects of a stroke differently. Some people, thank God, have no consequences, others may have temporary or permanent disabilities, for example:

- paralysis or loss of muscle movement; - speech or swallowing problems; - memory loss or difficulty understanding clearly; - pain or numbness in some parts of the body; - loss of ability to take care of oneself.

Remember that a person who has suffered a stroke needs care, love and understanding. Help such a person, be patient

Stroke treatment

Stroke treatment consists of 3 stages:

— provision of emergency medical care; - hospital inpatient facility; — rehabilitation (recovery).

In the first hours of a stroke, doctors provide emergency care.

In the first days in hospital, intensive therapy is provided, which reduces the risk of death, reduces brain damage and prevents the occurrence of a recurrent stroke.

Important! Many different medications can be used to treat any type of stroke, but remember - all medications can only be prescribed by your doctor and should be taken strictly as recommended!

Over the next weeks and months , the patient is prescribed medications, and his health status is constantly monitored (repeated examinations are carried out and tests are taken).

After treatment, the person is rehabilitated in the form of various procedures, physical therapy and massage.

Treatment of ischemic stroke

Treatment for this type of stroke aims to dissolve the clot that is blocking the flow of blood to the brain. Also, during treatment, doctors try to prevent recurrent stroke and other possible complications. For this, medications are used in the form of tablets, injections, droppers and various medical procedures.

Medicines prescribed for the treatment of ischemic stroke:

Tissue plasminogen activator. This is the main medicine that treats ischemic stroke by dissolving blood clots. But it is not suitable for everyone, as it has clear recommendations for use, many contraindications and side effects.

The drug can be used no later than 3 hours after the artery supplying the brain is blocked by a blood clot. It is best when the drug is administered to the patient within an hour of the onset of the stroke. If more than 3 hours have already passed, then the risk of using this drug is higher than the expected benefit. In 6% of people, administration of the drug can cause a hemorrhagic stroke; people over 75 years of age are especially susceptible to this course of events.

Tissue plasminogen activator can be administered if:

- it is precisely confirmed by tests that the stroke is ischemic; — less than 3 hours have passed since the onset of the stroke; — there were no head injuries or heart attacks for the next 3 months; - never had a stroke before; - in the previous 21 days there was no bleeding in the stomach, intestines, kidneys and no blood was noticed in the urine; - there have been no surgical operations in the previous 14 days; - upper blood pressure is below 185 mm Hg, and lower blood pressure is below 110 mm Hg. Art.; — tests showed that the blood clots normally; - blood sugar level is not too high.

Numerous contraindications and dangerous side effects reduce the frequency of use of tissue plasminogen activator.

Antiplatelet agents: Clopidrogel, Dipyridamole, etc.

Antiplatelet drugs do not dissolve a blood clot that has already formed, but they reduce the risk of new blood clots, thereby reducing the risk of another stroke.

Anticoagulants: Warfarin, Dabigatran, Heparin, etc.

Anticoagulants have more serious side effects than antiplatelet drugs, so they are prescribed less frequently.

Also, in the treatment of ischemic stroke, pills for high blood pressure are prescribed, as well as statins, which are taken for elevated levels of “bad” cholesterol.

Treatment of hemorrhagic stroke

Treatment of hemorrhagic stroke is aimed at quickly stopping the hemorrhage formed in the cerebral artery, as well as removing a blood clot from it that puts pressure on the brain. In such cases, neurosurgical surgery is indicated.

In addition, when treating hemorrhagic stroke, high blood pressure pills are prescribed, which must be taken strictly as prescribed by the doctor.

Recovery after stroke (rehabilitation)

After leaving the hospital, a person who has suffered a stroke needs recovery (rehabilitation). Restorative post-stroke therapy is an extremely important point in the treatment of stroke, because According to statistics, the risk of developing a secondary stroke is 4-14%.

It is very good to immediately send the person to a specialized rehabilitation center.

In such centers, a person will be helped to restore strength, body functions and return to independent life. The effect and duration of recovery depends on the area of ​​the damaged brain and the magnitude of the damage.

Procedures for recovery after a stroke

Therapeutic physical education (kinesitherapy). It is prescribed to restore full range of motion, strength and dexterity, as well as balance and self-care skills. Therapeutic exercises are carried out under the supervision of a doctor, with measurement of pulse and pressure. During physical education, it is necessary to give a person rest.

At first, this is passive gymnastics, the movements are performed for the patient by a rehabilitation therapist or trained relatives, then the exercises become more complicated, the person re-learns to sit, get up, stand and walk, eat, dress independently, and adhere to the rules of personal hygiene.

Massage. The massage consists of slowly and lightly stroking the muscles in which the tone is increased. Rubbing and gentle kneading are also possible.

Anesthesia. To relieve pain, procedures such as electrotherapy, magnetic therapy and laser therapy are recommended. The procedures relieve pain, activate the immune system, improve microcirculation, etc.

Improving tissue trophism. For this purpose they use: ozokerite, paraffin applications, hydro procedures, etc.

Fixing bandage. Prescribed for sore shoulder syndrome.

Speech rehabilitation. To restore your own speech and to understand the speech of others, classes are prescribed with a speech therapist-aphasiologist. They include in-class exercises as well as homework to improve writing, reading and arithmetic.

Psychological and social adaptation. For a person who has suffered a stroke, the support of friends, family and friends who could surround him with care and love is very important. A positive attitude is very important for a complete recovery. A healthy psychological climate in the family, smiles and help are needed. Be patient, communicate, find such a person an activity (hobby) that interests him, and take part in cultural and social events with him. It’s not for nothing that the Holy Scripture says: “A cheerful heart does good as medicine, but a sad spirit dries out the bones.”

Medications for recovery after stroke

After general recommendations for recovery after a stroke, we will consider medications that will help us carry out post-stroke therapy.

Medicines that improve blood supply to the brain: Pentoxifyline, Cavinton, Cerebrolysin, aspirin-based drugs.

Drugs that improve metabolic processes in brain cells: “Ceraxon”, “Actovegin”, “Cinnarizine”, “Ginkgo-fort”, “Cortexin”.

Nootropics (drugs that have a specific effect on higher brain functions). Such drugs can stimulate mental activity, activate cognitive functions, improve memory and increase learning ability: Piracetam.

Stroke Prevention

The main prevention of stroke is identifying and eliminating risk factors. Let's consider the basic rules and recommendations that reduce the risk of developing a stroke or recurrent stroke:

• stay calm and have a positive attitude;
• maintain a normal weight, avoid obesity;
• eat right, focusing your diet on fresh fruits and vegetables so that the body receives all the vitamins and microelements it needs;
• limit your salt intake;
• lead an active lifestyle;
• get enough sleep, the best sleep will be if a person goes to bed at 21:00-22:00;
• give up bad habits (alcohol, smoking, drugs);
• control your blood pressure (if you have hypertension);
• monitor your blood sugar levels, which can be done using a glucometer;
• control the level of “bad” cholesterol in the blood.

Local physician at polyclinic No. 5 A.K. Shevchuk