Stroke - essence, causes, signs, symptoms, consequences, diagnosis (tests), treatment, rehabilitation, prevention

The spread of vascular diseases of the brain in recent years has, unfortunately, an increasing trend.

Among them is the most dangerous manifestation of cerebral vascular insufficiency - cerebral stroke (Latin “insultus” - “attack”).

Stroke is the disease of the century. The frequency of its primary cases during the year ranges in economically developed countries from 1.27 to 7.4 per 1000 population. There is also some rejuvenation of the patient population. In Russia, ischemic stroke ranks second in the structure of overall mortality after coronary heart disease. Mortality rates for men and women are 184.6 and 137.3 per 100,000 population, respectively. Only 13% of patients who have suffered an ischemic stroke return to their previous work activity.

What is a stroke

The essence of a stroke is the cessation of blood supply and functioning of a part of the brain as a result of damage to a vessel.
The larger the affected area, the more severe the stroke. Necrosis of a portion of the brain substance is called an infarction [3]. There is a high risk of death in the first few hours, and then in the period up to 28 days after a vascular accident. The annual mortality rate from stroke in the Russian Federation is 374 cases per 100,000 [10]. In 2018, 35% of patients died in the acute period of stroke; by the end of the first year, this figure increases by 15%, and in general, in the first 5 years, the mortality rate of strokes is 44% [11]. The mortality rate from stroke was 92.9 per 100,000 population, and the hospital mortality rate was 19.1% [5].

Long-term disability is most likely for patients who have suffered a stroke. The prevalence of primary disability due to stroke in 2018 was 3.2 per 10 thousand population [2]. Of these, 31% need constant care, 20% have severe mobility limitations, and only 8% return to work [3]. The prevalence of recurrent strokes in 2014 was 0.79%, of which ischemic

strokes account for 87.5% [9].

First aid

If your arms and legs suddenly become weak and numb, your face is distorted, speech and vision are impaired, consciousness is upset, dizziness appears, there is reason to think that a cerebrovascular accident has occurred.

There is no need to wait until the next day to invite a local doctor or family doctor; you need to urgently call an ambulance. The best option is immediate hospitalization.

But even before the ambulance arrives, it is necessary to provide proper care for the patient at home and carry out the first treatment measures.

Create a calm, comfortable position for the patient, preferably lying on his back with a small pillow under his head. The head and shoulders should lie on a pillow to prevent flexion of the neck and deterioration of blood flow through the vertebral arteries. If a person falls as a result of an attack, when lifting and laying him down, try (this is very important) to avoid sudden movements of his head. You feel that you can’t cope alone, don’t rush - it’s better to stay on the floor until help arrives.

Pay attention to the patency of the upper respiratory tract, especially in cases of impaired consciousness. Be sure to remove removable dentures from the mouth. If there is excessive salivation or accumulation of mucus in the oropharynx and nasopharynx, carefully turn the patient’s head to the side. Be sure to open a window or window - fresh air is necessary.

Monitor your blood pressure. Every person, and especially those suffering from hypertension (himself or his close relatives), should know the blood pressure numbers at which he feels comfortable. Then, when neurological symptoms appear, it is not difficult to trace on what blood pressure indicators they developed. If there are elevated blood pressure numbers, it is recommended to give antihypertensive drugs that the patient usually uses (hypertensive patients always have them in their home medicine cabinet). After giving the medicine, measure your blood pressure - it should be 5-10 mm Hg. column higher than the numbers usual for the patient.

A sharp decrease in blood pressure below the patient’s “working” numbers is strictly contraindicated; this will lead to an increase in cerebral ischemia and an increase in the size of the pathological focus.

To reduce high blood pressure before the ambulance arrives, it is recommended to give clonidine under the tongue. Sometimes a hood can help.

In the acute period of a stroke, you should avoid taking so-called peripheral vasodilators - papaverine, nicotinic acid, no-shpa, nicoshpan. They contribute to the development of the “steal” syndrome in the ischemic zone - there is a predominant dilation of unaffected vessels and an increase in cerebral blood flow in non-ischemic areas. But if nothing else is at hand, it is still better to lower blood pressure with these drugs than to leave it high.

The latest clinical and experimental studies have shown that there is a “temporary therapeutic window” within which it is possible not only to influence the functional state of the brain, but even to prevent the formation of its infarction. However, this can be achieved completely only within 6-8 minutes after the appearance of the first clinical symptoms. However, even after 3-6 hours it is possible to ensure significant reversibility of functional changes in the brain. Most drugs that protect tissue from the harmful effects of ischemia (they are called metabolic) are prescribed only by a doctor! They are taken under the control of clinical and laboratory parameters.

However, there are metabolically active drugs that must be given to the patient as quickly as possible before the ambulance arrives. This is glycine, cerebrolysin or nootropil. They are safe, do not produce unwanted side effects, and will not cause harm even when the diagnosis has not been established and the stroke is, say, hemorrhagic in nature, that is, caused by bleeding in the brain.

Causes of stroke

Depending on the cause of cerebrovascular accident, ischemic and hemorrhagic strokes are distinguished.

Ischemic stroke occurs as a result of blockage of cerebral vessels by a blood clot, when gradually less and less blood flows to an area of the brain. Hemorrhagic stroke develops as a result of rupture of a vessel and hemorrhage in the brain tissue, as a result of which the blood supply to its area abruptly stops. Hemorrhage can be into the subarachnoid space (SAS) or directly into the cerebral substance (ICH). The ratio of ischemic and hemorrhagic strokes is 4-5:1 [4].

Pathologically, a stroke can be cardioembolic, lacunar, atherothrombotic, or another, including unknown, etiology (TOAST classification) [10].

Predisposing factors:

men from 45 to 59 years old;
age 70 years and older (for both sexes) [4];
arterial hypertension;
atrial fibrillation;
atherosclerosis of cerebral vessels;
coagulopathy, thrombophilia, anemia;
arteriovenous malformations;
osteochondrosis with damage to the vertebral artery;
brain tumors;
dyslipoproteinemia;
obesity;
diabetes;
intermittent claudication;
mechanical prostheses of heart valves and blood vessels;
IHD, myocardial infarction less than 6 months before the stroke;
other cardiac diseases;
smoking, alcoholism;
family history of stroke;
sedentary lifestyle;
stress [1, 3].

Acceptable indicators and pressure deviations after impact

What blood pressure should a patient have after a stroke? Everything will depend on the type of pathology.

Ischemic form

During the first few hours after the formation of the condition, almost all patients experience high blood pressure. This is a protective reaction of the brain aimed at stabilizing the work of the myocardium. That is why a specialist should select antihypertensive drugs, taking into account the current condition of the patient.

Incorrectly selected medications can reduce blood pressure too much. The worst outcome in this case may be the death of a person. In addition, recovery after a stroke will be longer and more difficult.

Indications for emergency reduction of blood pressure are:

increase to 180/220–100/120 mm. rt. st;
the need to administer an antithrombotic agent;
development of systemic circulatory failure;
diagnosing aneurysm/arteriovenous malformation of cerebral vessels;
disorders of the kidneys.

During the first 48–72 hours after an ischemic stroke has occurred, blood pressure can be reduced by no more than 15% relative to the existing one. At this time, increased blood pressure is normal.

Important! In patients who do not have a history of hypertensive pathology, blood pressure should not fall below 165/95 mm. rt. Art. In the presence of the disease, the minimum level is determined by 185/105 mm. rt. Art.

It is very important to protect the patient from factors that can provoke a sharp increase in blood pressure. These include nervous tension, severe pain, and fluid retention.

Hemorrhagic form

This type of stroke occurs against the background of a significant increase in blood pressure, so antihypertensive therapy should be started as early as possible. Taking medications helps:

reducing the volume of the hematoma, stopping its spread;
decrease in intracranial pressure;
blocking the development of swelling of brain tissue.

The critical level of blood pressure, upon reaching and overcoming which it is necessary to take measures to reduce, is considered to be 140/90 mm. rt. Art. But the decline should be gradual. During the day, it can be lowered only by 20% relative to the current one.

Signs of an incipient stroke

The onset of a hemorrhagic stroke is characterized by the following symptoms:

severe headache;
increased blood pressure;
vomit;
dizziness;
loss of consciousness;
weakness in the limbs;
visual impairment;
seizures [1].

The onset of ischemic stroke is gradual; within an hour, some of the following symptoms appear:

facial asymmetry, numbness;
difficulty speaking – incoherent, impaired understanding;
double vision, visual disturbances;
headache;
numbness, limited mobility in the limbs, often on one side;
dizziness, imbalance, staggering, staggering gait;
confusion with disorientation, subsequently there may be loss of consciousness [3].

If one or more of these signs appear, you should:

Sit the patient down, providing access to fresh air.
Call emergency medical help immediately.
If the patient is conscious and able to chew and swallow, give him one aspirin tablet.

The patient must be hospitalized in a neurological or neurosurgical department, where stroke treatment will be carried out. The sooner the patient is in the hospital, the more effective the therapy.

First signs and symptoms

Before a stroke, drowsiness, headache, numbness of the limbs, fatigue, spots before the eyes, nausea, dizziness, temperature fluctuations, and blood pressure jumps appear. These are the harbingers or first signs of a stroke that appear several hours or days before the disaster. Most often, these symptoms are ignored, or they are attributed to fatigue and overwork.

Symptoms of a stroke themselves are divided into general cerebral and focal. They can be of varying degrees of severity depending on the prevalence of the pathological process.

General cerebral symptoms: headache, impaired consciousness up to loss of consciousness, stupor, agitation or weakness, disorientation in space and time, sweating, feeling hot, convulsions. Makes you feel sleepy and sometimes chills.
The focal abnormalities of a stroke depend on which area of the brain is affected. They can be unilateral or bilateral. This group includes disturbances in speech, vision (visual hallucinations), gait, movements up to paralysis, and sensitivity.

Symptoms of ischemic cerebral stroke develop gradually, with focal symptoms predominant.

With a hemorrhagic stroke, the onset is rapid, with a predominance of cerebral symptoms.

There are several stages in the development of a stroke: the acute period (from the moment of the stroke to 3 weeks on average), the recovery period - from 2 weeks to 24 months.

Symptoms of a stroke

Stroke leads to various brain injuries, depending on the location of the lesion and the pathological type of cerebrovascular accident:

disturbances of movement in the limbs: from restrictions (paresis) to complete paralysis. When the lesion is localized on the right, the left limbs suffer; with a left-sided lesion, right hemiparesis is formed; in some cases, movements in all limbs may stop (tetraparesis or double hemiparesis);
sensory disturbances on one or both sides;
speech disorders (dysarthria - poor articulation; aphasia - inability to pronounce and understand words, write and read);
ataxia (impaired coordination of movements, “overshooting”, unsteadiness, imbalance, tremor);
visual impairment: from blindness to double vision and gaze paresis;
hearing impairment and dizziness;
violation of mental functions (consciousness, thinking, attention, memory, will, behavior);
paresis of the soft palate and pharynx, swallowing disorders;
disorders of urination and defecation;
depression of respiration and vascular tone;
increased intracranial pressure;
patients complain of headaches, vomiting, hiccups, yawning, shoulder pain;
consciousness is gradually depressed to the point of coma [1, 3].

Causes of death may include cerebral edema, pneumonia, heart failure, and recurrent stroke. In severe cases, “locked-in syndrome” may develop: the patient is conscious, but cannot move, swallow or speak [3].

Who is at risk

There are people who need to be especially wary of developing a stroke, as they are at risk.

Among them:

Persons with hypertension.
Patients with diabetes.
Men and women over 65 years of age.
People with abdominal obesity.
Persons with a hereditary predisposition to vascular pathologies.
Patients who have previously had a stroke or heart attack.
Patients with diagnosed atherosclerosis.
Women over 35 years of age taking oral contraceptives.
Smokers.
People suffering from heart rhythm disturbances.
People with high cholesterol levels.

Most often, patients with the listed diagnoses are registered at the dispensary. Special mention should be made of people living in a state of chronic stress. Emotional stress negatively affects all systems of the body and can cause a stroke.

Consequences of a stroke

There are transient ischemic attack (less than a day), minor stroke (from 1 day to 3 weeks) and stroke with persistent residual effects. The consequences of a stroke are expressed mainly in motor and sensory disorders, the formation of muscle contractures (pronounced constant restriction of movements in the joints), speech and swallowing disorders. General symptoms may also remain, including confusion, disturbances in thinking, will, and emotional regulation. Complications can develop: from epilepsy to bedsores, encephalopathy and anxiety-depressive syndrome [1, 3].

Diagnostic methods

It is important to quickly distinguish a stroke from other diseases that can lead to the development of similar symptoms. It is almost impossible to do this on your own, as well as to determine the type of vascular accident.

The main difference between an ischemic stroke is a gradual increase in symptoms that do not lead to loss of consciousness. With hemorrhagic hemorrhage, the patient passes out quickly. However, stroke does not always have a classic course. The disease may begin and progress atypically.

Diagnosis begins with examination of the patient. The doctor collects anamnesis and determines the presence of chronic diseases. Most often, you can get information not from the victim himself, but from his relatives. The doctor performs an ECG, determines the heart rate, takes a blood test, and measures blood pressure.

It is possible to make the correct diagnosis and obtain maximum information about the patient’s condition thanks to instrumental diagnostic methods. The best option is a CT scan of the brain. Performing an MRI is difficult because the procedure takes a long time. It takes about an hour. It is impossible to spend this amount of time diagnosing an acute stroke.

Computed tomography allows you to clarify the type of pathology, where it is concentrated, to understand how badly the brain is damaged, whether the ventricles are affected, etc. The main problem is that it is not always possible to perform a CT scan in the shortest possible time. In this case, doctors have to focus on the symptoms of the disease.

To determine the source of the stroke, the method of diffusion-weighted tomography (DWI) is used. The information will be received within a few minutes.

Other examination methods include:

Lumbar puncture.
Cerebral angiography.
Magnetic resonance angiography. It is performed without the introduction of a contrast agent.
Doppler ultrasound.

Once the diagnosis is made, the doctor will immediately begin treatment.

Diagnosis of strokes

First of all, it is necessary to conduct a detailed neurological examination. Instrumental diagnostic studies and laboratory tests are also prescribed. In case of a stroke, in the first hours, an MRI or CT scan of the brain is performed, if necessary, CT or MR angiography, color Doppler mapping of blood flow, ECG or Holter monitoring, echocardiography as indicated, monitoring of blood pressure, saturation, assessment of the risk of developing bedsores, assessment of swallowing function [ 1, 3, 6].

Tests for stroke

Complete clinical blood test, including erythrocyte sedimentation rate (ESR).
Biochemical blood test with determination of C-reactive protein and homocysteine, glucose level, platelet count, activated partial thromboplastin time, INR.
Interleukin 10.
Extended coagulogram.
Determination of acid-base status.
General urine analysis.

To prepare for neurosurgical intervention, a blood test is additionally performed for hepatitis, syphilis, HIV, blood group and Rh factor determination.

Diagnostic methods

To determine the source of the stroke, the method of diffusion-weighted tomography (DWI) is used. The information will be received within a few minutes.

Other examination methods include:

Lumbar puncture.
Cerebral angiography.
Magnetic resonance angiography. It is performed without the introduction of a contrast agent.
Doppler ultrasound.

Once the diagnosis is made, the doctor will immediately begin treatment.

Stroke treatment

Treatment of stroke is regulated by relevant clinical guidelines and the Procedure for providing medical care to patients with acute cerebrovascular accident. In the first hours, thrombolytic therapy is carried out and subsequently - prevention of thrombus formation. For hemorrhagic stroke, neurosurgery may be performed. They normalize blood pressure, water-electrolyte balance, glucose levels in peripheral blood and urine, support the basic vital functions of the body and prevent complications. Drug therapy is also aimed at improving the affected functions of the nervous system [1, 3, 6].

Causes of blood pressure surges

A sharp fluctuation in blood pressure after a stroke occurs when the organs and systems of the body are unable to perform their functions. Most often it is the brain that is affected. Against the background of unstable blood pressure, both cardiac and peripheral circulation worsens, and the destruction of the walls of blood vessels also occurs. The patient develops an acute form of atherosclerosis. The development of recurrent strokes cannot be ruled out.

The main danger lies not in the increase or decrease in pressure, but in its constant fluctuation

The leading causes of sudden changes in blood pressure that occur after a stroke are:

disturbances in the functioning of the central nervous system;
low mobility of the vasomotor center;
high blood sugar levels;
hormonal imbalance;
changes in the electrolyte composition of the blood.

Important! With a hemorrhagic stroke, the risk of developing a second stroke is high. This usually happens on the fifth or sixth day after the first blow.

Stroke rehabilitation

Stroke is a disease in which rehabilitation and care are of the utmost importance.
Recovery from a stroke begins in intensive care, from the moment vital functions are stabilized. A multidisciplinary rehabilitation team works with the patient, which includes a rehabilitation doctor, physical therapist or exercise therapy instructor, speech therapist, massage nurse, physiotherapist and physical therapy nurse, psychologist, occupational therapist, guard and rehabilitation nurse. Diagnosis is carried out using special scales that reflect the degree of dysfunction and limitations in the patient’s activity, the influence of environmental factors on the rehabilitation potential. The rehabilitation process continues throughout the entire period of hospitalization. At the second stage, patients with serious disabilities who are unable to move independently are sent to rehabilitation departments or specialized hospitals. Those who can walk independently or with support are rehabilitated in outpatient centers based in clinics and sanatoriums.

The rehabilitation process should not be interrupted, so classes must be continued at home. Of course, there are no high-tech robotic complexes or physiotherapeutic equipment at home, but exercise therapy, massage, and work with a psychologist, speech therapist and occupational therapist are possible. For this purpose, telemedicine technologies are used and visits to rehabilitation specialists are organized.

The individual rehabilitation program includes not only a referral for rehabilitation treatment, but also technical means of rehabilitation. However, usually relatives also have to devote significant physical and financial resources to achieve the best effect [7].

Treatment and rehabilitation

The patient receives treatment in a hospital. All patients with suspected stroke are hospitalized on an emergency basis. The optimal period for providing medical care is the first 3 hours after a brain accident has occurred. The person is placed in the intensive care unit of a neurological hospital. After the acute period has been overcome, he is transferred to the early rehabilitation unit.

Until the diagnosis is established, basic therapy is carried out. The patient’s blood pressure is adjusted, the heart rate is normalized, and the required blood pH level is maintained. To reduce cerebral edema, diuretics and corticosteroids are prescribed. Craniotomy is possible to reduce the degree of compression. If necessary, the patient is connected to an artificial respiration apparatus.

Be sure to direct efforts to eliminate the symptoms of stroke and alleviate the patient’s condition. He is prescribed medications to lower body temperature, anticonvulsants, and antiemetics. Medicines that have a neuroprotective effect are used.

Pathogenetic therapy is based on the type of stroke. In case of ischemic brain damage, it is necessary to restore nutrition to the affected area as quickly as possible. To do this, the patient is prescribed drugs that resolve blood clots. It is possible to remove them mechanically. When thrombolysis fails, the patient is prescribed Acetylsalicylic acid and vasoactive drugs.

In case of a stroke, it is extremely important to provide timely treatment to the damaged areas of the brain. A course of use of the drug accelerates the process of recovery of brain cells after a stroke, even in cases of impaired blood circulation or hypoxia. This allows for rapid restoration of memory, thinking, speech, swallowing reflex and restoration of other functions of daily activities. Gliatilin has a positive effect on the transmission of nerve impulses, protects brain cells from repeated damage, which prevents the risk of recurrent stroke.

The drug is well tolerated by patients; it is contraindicated for use by pregnant, lactating women and people with hypersensitivity to choline alfoscerate.

Courses will need to be taken regularly. You definitely need to do physical therapy, undergo physical therapy, and visit a massage therapist. After a stroke, many patients have to restore motor skills over a long period of time and learn to care for themselves independently.

Relatives and friends should provide support to the patient and not leave him alone with the problem. Psychologists are involved in the work. Sessions with a speech therapist are often required.

Prevention of strokes

Hereditary predisposition to stroke, the presence of cardiac diseases, pathology of blood vessels and blood composition, age over 40 years, obesity and diabetes require a number of preventive measures:

Maintaining normal blood pressure, taking antihypertensive drugs as prescribed by a doctor, monitoring blood pressure.
Maintaining a normal level of physical activity, exercise, walking 30-40 minutes a day (for example, walking the dog).
Conducting preventive examinations, including a standard set of laboratory parameters. During a preventive examination, the following tests are additionally required: gene diagnosis of CADASIL syndrome using the PCR method, plasma factors of the blood coagulation system, antibodies to prothrombin of the IgG and IgM classes to determine the risk of thrombosis, determination of polymorphisms associated with the risk of arterial hypertension, diabetes mellitus, lipid disorders exchange, in order to identify a predisposition to diseases that increase the risk of stroke, von Willebrand factor (a glycoprotein that ensures the formation of blood clots), complex laboratory tests for preclinical diagnosis of cardiovascular diseases are offered (“ELI-ANKOR-Test-12”, “Cardiorisk”).
Avoiding chronic and acute stress, maintaining mental hygiene.
Normalization of weight (BMI <25 kg/m2).
Healthy eating (for example, Mediterranean diet, limiting salt to 5 5 g/day).
Quitting smoking and taking psychoactive substances.
Treatment of diseases that are a risk factor for stroke [8, 11].

What blood pressure can trigger the development of a stroke?

At what blood pressure level can a stroke occur and can the condition develop at normal blood pressure? It is worth noting that most often a stroke occurs in hypertensive patients. The reasons are:

Stably high blood pressure, which does not decrease even while taking medications;
sharp jumps in indicators caused by a stressful situation or significant physical activity;
refusal of treatment for hypertension and heart disease.

Doctors call the physiological level of blood pressure, at which all body systems operate in a natural mode, a level of 120/80 mm. rt. Art. When it increases to 180/120, we can talk about the development of a hypertensive crisis, which can quite easily turn into an apoplexy (stroke).

The danger in terms of the development of pathology is represented by too small a difference between the upper and lower blood pressure readings. If it is less than 40 units, then the likelihood of blockage of the vascular lumen increases significantly. Therefore, a blood pressure of 130/110 is more likely to trigger the development of a stroke than a blood pressure of 160/90.

Bibliography

Hemorrhagic stroke in adults: clinical recommendations of the Ministry of Health of the Russian Federation, 2021. Developers: Association of Neurosurgeons of Russia. - Electronic text. - URB: (access date 08/18/2020).
Efremova M.D. Stroke as an urgent socio-psychological problem / M.D. Efremova – electronic text//Skif. Questions of student science.- 2021 - No. 2(24) URB: (date of access 08/17/2021) Access mode: Cyberleninka electronic library system. — Text: electronic.
Ischemic stroke and transient ischemic attack in adults: clinical recommendations of the Ministry of Health of the Russian Federation, 2021 developers: All-Russian Society of Neurologists, National Association against Stroke, Association of Neurosurgeons of Russia, Association of Neuroanesthesiologists and Neuroreanimatologists, Union of Rehabilitologists of Russia. - Electronic text. - URB: ( access date 08/18/2020).
Machinsky P.A. Comparative characteristics of incidence rates of ischemic and hemorrhagic stroke in Russia / P.A. Machinsky, N.A. Plotnikova, V.E. Ulyankin [and others] – Direct text.// News of higher educational institutions. Volga region. Medical Sciences.- 2021.- “2(50)-P.112 – 132 DOI 10.21685/2072-3032-2019-2-11.
Monitoring the implementation of the federal project “Combating Cardiovascular Diseases” - Presentation Department of Organization of Medical Care and Sanatorium Affairs of the Ministry of Health of the Russian Federation URB: (date of access 08/17/2021).
Order of the Ministry of Health of the Russian Federation dated November 15, 2012 N 928n “On approval of the Procedure for providing medical care to patients with acute cerebrovascular accidents.” — URB: (access date 08/17/2021) Access mode: Electronic library system “Garant”. — Text: electronic.
Order of the Ministry of Health of the Russian Federation dated July 31, 2021 No. 788n “On approval of the Procedure for organizing medical rehabilitation of adults.” – URB: (date of access 08.17.2021).- Access mode: Electronic library system “Garant”. — Text: electronic.
Prevention of cerebrovascular accidents: textbook. manual / Compiled by: L.B. Novikova, A.P. Akopyan. – Ufa: Publishing house of the State Budgetary Educational Institution of Higher Professional Education BSMU of the Ministry of Health of Russia, 2015.-58 p.
Stakhovskaya L.V. Analysis of epidemiological indicators of recurrent strokes in the regions of the Russian Federation (based on the results of the territorial-population register 2009-2014) / L.V. Stakhovskaya, O.A. Klochikhina, M.D., Bogatyreva, etc.]. CONSILIUM MEDICUM, 2021, vol. 5, no. 9, p. 8-11.
Shamalov N. A. Analysis of the dynamics of the main types of stroke and pathogenetic variants of ischemic stroke / N. A Shamalov, L. V Stakhovskaya, O. A Klochikhina [and others]. Direct text. // Journal of Neurology and Psychiatry named after. S.S. Korsakov. Special issues. 2019;119(3-2):5-10. doi.org/10.17116/jnevro20191190325.
1RRE Electronic edition. Updated daily Stroke Day is celebrated on October 29, 2021 URB: (accessed 08/17/2021).

Author:

Pugonina Tatyana Alekseevna, Therapist

Possible consequences, complications

The main danger of a stroke is death. If a person survives, the disease will still make itself felt with certain complications.

Early consequences include:

Brain swelling.
Coma.
Pneumonia.
Paralysis. It can be partial or complete. Most often, one half of the body is affected.
Repeated stroke.
Bedsores.
Mental disorders. They can manifest themselves in moodiness, irritability, aggression, and anxiety. Sometimes dementia develops.
Sleep disorders.
Myocardial infarction, gastric ulcer. These disorders develop against the background of increased levels of stress hormones.

After an ischemic stroke, death occurs in 15-25% of cases. Hemorrhagic damage to the blood vessels of the brain leads to the death of 50-60% of patients. The cause of death is precisely severe complications, for example, pneumonia or acute heart failure. The first 3 months after a stroke are considered the most dangerous.

Arms recover worse in patients than legs. A person's future health is determined by the severity of brain damage, the speed of medical care, his age and the presence of chronic diseases.

Long-term consequences include:

Formation of blood clots in various parts of the body.
Depression.
Speech problems.
Memory loss.
Deterioration of intellectual abilities.

After a stroke, you have to deal with the consequences for many months. Sometimes a person never manages to fully recover. For rehabilitation to be as successful as possible, you must strictly follow all the doctor’s instructions.

Stroke is a serious pathology because it affects the brain. Therefore, even the slightest suspicion of a developing vascular accident is a reason to urgently seek medical help.

Who is at risk

There are people who need to be especially wary of developing a stroke, as they are at risk.

Among them:

Persons with hypertension.
Patients with diabetes.
Men and women over 65 years of age.
People with abdominal obesity.
Persons with a hereditary predisposition to vascular pathologies.
Patients who have previously had a stroke or heart attack.
Patients with diagnosed atherosclerosis.
Women over 35 years of age taking oral contraceptives.
Smokers.
People suffering from heart rhythm disturbances.
People with high cholesterol levels.

Ischemic stroke (cerebral infarction) - symptoms and treatment

General events

When treating ischemic stroke, it is customary not to reduce blood pressure quickly if it is high, especially in the first days of the disease.
Low blood pressure should be increased - this is done by doctors; do not give the patient any medications on your own. Uncontrollable, severe vomiting is a common problem in the period immediately after a stroke, especially when the basilar artery is affected. This creates problems in the patient's nutrition. If vomiting does not stop, or there is dysphagia, then a feeding tube is inserted. The lack of electrolytes is compensated for by infusion therapy. The airway should be closely monitored.

Thrombolytic therapy

Thrombolytic therapy is the only therapy for acute ischemic stroke whose effectiveness has been proven in large studies.

No more than 4.5 hours should pass from the onset of the first symptoms of a stroke to the administration of a thrombolytic, so prompt hospitalization is important.

Vascular occlusion occurs in the arterial or venous bed. Thrombotic medications dissolve the clot, but the drug must be delivered to the thrombotic area.

Thrombolytic agents first appeared in the 1940s. The active development of drugs in this group has led to the fact that there are currently five generations of thrombolytics:

The first thrombolytics are natural substances that convert plasmagen into plasmin, thereby causing active bleeding. These ingredients are isolated from the blood. This group of drugs is rarely used, as severe bleeding is possible. This generation includes: Fibrinolysin, Streptokinase, Urokinase, Streptodecase, Thromboflux.
The second generation are substances obtained based on the achievements of genetic engineering using bacteria. This generation of drugs has been well studied and has virtually no side effects. Act directly on blood clots. This generation includes: Alteplase, Actilyse, Prourokinase, Gemaz. Purolase, Metalise.
Third generation - these drugs are able to quickly find a blood clot and act on it for a longer period of time. Most effective in the first three hours: Reteplase, Tenecteplase, Lanoteplase, Antistreplase, Antistreptolase.
Fourth generation - these drugs are in development and are characterized by a rapid and intense effect on the blood clot. Insufficiently studied.
The fifth generation is a combination of natural and recombinant active substances.

In the recovery phase, when the patient’s condition almost always improves to one degree or another, speech therapy assistance, as well as occupational therapy and exercise therapy, are important.

Infusion therapy

Anticoagulants (heparin and indirect anticoagulants) are prescribed only when the doctor’s instructions will be followed and it is possible to monitor blood clotting [8].

Anticoagulants

Anticoagulants prevent the formation of fibrin threads and thrombus formation, help stop the growth of already formed blood clots, as well as the effect of endogenous fibrinolytic enzymes on blood clots [11].

Anticoagulant treatment can be started only after intracerebral bleeding has been ruled out.

Direct coagulants : heparin and its derivatives, direct thrombin inhibitors, as well as selective inhibitors of factor X (Stewart-Prower Factor - one of the blood clotting factors).

Indirect anticoagulants:

Vitamin K antagonists: phenindione (Phenilin), warfarin (Warfarex), acenocoumarol (Sincumar);
Heparin and its derivatives: heparin, antithrombin III, dalteparin (Fragmin), enoxaparin (Anfibra, hemapaxan, Clexane, Enixum), nadroparin (Fraxiparin), parnaparin (Fluxum), sulodexide (Angioflux, Vessel Due F), bemiparin (Cibor);
Direct thrombin inhibitors: bivalirudin (Angiox), dabigatran etexilate (Pradaxa);
Selective factor X inhibitors: apixaban (Eliquis), fondaparinux (Arixtra), rivaroxaban (Xarelto).

Antiplatelet agents

The administration of antiplatelet agents improves the passage of fluid in the brain tissue and prevents the development of acute disruption of the blood supply to the brain [6].

Antiplatelet agents prevent platelets from sticking together, thereby preventing the formation of blood clots.

Classification of antiplatelet agents by mechanism of action:

aspirin, indobufen, trifluse (stop the action of cyclooxygenase-1, COX-1);
ticlopidine, clopidogrel, prasugrel, ticagrelor, cangrelor (stop the functioning of the ADP receptor P2Y12 on platelet membranes);
abciximab, monofram, eptifibatide, tirofiban; xymelofiban, orbofiban, sibrafiban, lotrafiban and others (glycoprotein (GP) Iib/IIIa antagonists);
dipyridamole and triflusal (cAMP phosphodiesterase inhibitors);
iloprost (adenylate cyclase enhancer);
ifetroban, sulotroban and others (suppress the TXA2/PGH2 receptor);
atopaxar, vorapaxar (antagonize the AR receptor (protease activated receptors) of thrombin).

Aspirin is a commonly used drug in this group. If anticoagulants are contraindicated, then antiplatelet agents can be used.

Surgery

Carotid endarterectomy is a prophylactic surgical procedure performed to remove atherosclerotic plaque from the arteria carotis communis (common carotid artery).

When a cerebellar stroke develops with compression of the brain stem, in order to save the patient’s life, a surgical operation is performed to relieve intracranial pressure in the posterior cranial fossa.

Decongestant therapy

There are different and quite opposite opinions regarding the use of corticosteroids for ischemic stroke, but doctors still actively use them to reduce cerebral edema: they prescribe dexamethasone 10 mg intravenously or intramuscularly, then 4 mg intravenously or intramuscularly every 4-6 hours.

Osmotic agents . Mannitol - increases plasma osmolarity, thereby fluid from tissues, including from the brain, moves into the bloodstream, creating a pronounced diuretic effect, and a large amount of fluid is removed from the body. Cancellation can have a rebound effect.

Anticonvulsants

They must be prescribed for the development of ischemic stroke with epileptic seizures.

Rehabilitation after stroke

Rehabilitation measures begin in the early period of the disease and continue after discharge from the hospital. They include not only drug treatment, massage, physical therapy, speech therapy classes, but also require the involvement of other specialists in psychological, social and labor rehabilitation.

Along with the restoration of impaired functions, rehabilitation includes:

prevention of post-stroke complications;
prevention of recurrent strokes.

Basic principles of rehabilitation after stroke:

early start of rehabilitation measures;
systematicity and duration, which is possible with a well-organized step-by-step construction of rehabilitation;
inclusion of specialists of various profiles in the rehabilitation process, individualization of rehabilitation programs;
active participation in the rehabilitation process of the patient himself, his relatives and friends.

The duration of rehabilitation is determined by the timing of restoration of impaired functions. Recovery of motor functions occurs mainly in the first 6 months after a stroke. During this period, intensive motor rehabilitation is most effective. Rehabilitation treatment for patients with aphasia should be longer and carried out during the first 2-3 years after a stroke.

The complexity of rehabilitation consists of using not one, but several methods aimed at overcoming the defect.

For movement disorders, the rehabilitation complex includes:

methods of kinesiotherapy (passive and active gymnastics, training in walking and self-care skills);
correction of motor dysfunction using biofeedback and electrical stimulation using feedback;
methods of overcoming spasticity and treatment of arthropathy.

For speech disorders, the main thing is regular classes with a specialist in the restoration of speech, reading and writing (speech therapist-aphasiologist or neuropsychologist).

The following model of staged rehabilitation after a stroke is most optimal:

Stage 1 - rehabilitation begins in the angioneurological department (or in the regular neurological department of a clinical hospital), where the patient is delivered by ambulance;

Stage 2 - at the end of the acute period (the first 3-4 weeks), the following options for referring patients are possible:

1st option - the patient with complete restoration of impaired functions is discharged for outpatient follow-up treatment or transferred to a sanatorium;
2nd option - a patient with a pronounced motor deficit, who by the end of the acute period is still unable to move independently or moves with great difficulty, and needs outside help with self-care, is transferred to the rehabilitation department of the hospital where he was taken by ambulance;
Option 3 - patients with moderate and mild motor defects, who can move independently within the hospital and provide basic self-care, are transferred to a rehabilitation center. Patients who, during their stay in the rehabilitation department of the hospital (2nd option) have learned to walk independently and simply take care of themselves in everyday life, are also transferred to the rehabilitation center.

Stage 3 - outpatient rehabilitation: rehabilitation in special rehabilitation sanatoriums and at home.

Outpatient rehabilitation is carried out on the basis of rehabilitation departments of clinics or recovery rooms or in the form of a “day hospital” at rehabilitation departments of hospitals and rehabilitation centers. In rehabilitation sanatoriums there can be patients who can fully care for themselves and move independently not only indoors, but also outside. For those patients who cannot independently get to a clinic or day hospital, rehabilitation assistance (classes with a physical therapy methodologist and classes on speech restoration) is provided at home, with the obligatory training of relatives.

Contraindications and limitations to active rehabilitation

The following concomitant diseases limit or prevent active motor rehabilitation:

frequent attacks of angina pectoris;
heart failure;
high and poorly controlled blood pressure;
chronic pulmonary diseases: bronchial asthma with frequent attacks, obstructive bronchitis;
severe forms of diabetes mellitus;
cancer;
acute inflammatory diseases;
some diseases and pathologies of the musculoskeletal system: severe arthritis and arthrosis, amputated limbs.

Psychoses and severe cognitive impairment (dementia) are limitations for carrying out not only motor, but also speech rehabilitation.

There are limitations for rehabilitation treatment in conventional rehabilitation centers: extremely limited mobility of patients (lack of independent movement and self-care), impaired control of the functions of the pelvic organs, and impaired swallowing. Rehabilitation of such patients, as well as patients with severe cardiac and pulmonary pathologies, is carried out in rehabilitation departments located on the basis of large clinical multidisciplinary hospitals, according to special rehabilitation programs.