Recurrent ischemic stroke: survival prognosis

Repeated ischemic stroke occupies one of the first places among diseases leading to disability and death. If life expectancy after the first stroke averages eight to nine years, then a second acute cerebrovascular accident can reduce it to two to three years. Therefore, in modern neurology clinics, one of which is the Yusupov Hospital, a large role is given to secondary stroke prevention.

It is proper prevention and treatment that can prevent the recurrence of a vascular accident, because, according to statistics, the probability of a second stroke within a year after the first is about 15%, and after a few years - up to 30-40%.

Who's at risk

After a primary stroke, the body retains mechanisms that provoke the following development of events: intravascular thrombus formation, vascular atherosclerosis. The patient, as a rule, also has a number of concomitant diseases, often in advanced forms: hypertension, diabetes mellitus, arrhythmia, heart failure and others. Preventing recurrent ischemic stroke in such cases is a rather difficult task, but thanks to the efforts of qualified specialists at the Yusupov Hospital, it is feasible.

Repeated ischemic stroke sometimes threatens even patients who are unaware that they have already suffered a vascular accident: patients with short-term disturbances of cardiac or cerebral circulation, the so-called transient ischemic attacks, manifested by the sudden onset of headache, dizziness, numbness of the arm or leg - symptoms which are often ignored, despite the fact that they are the first alarm bells preceding a stroke. The threat of vascular attack increases even more with transient loss of vision, speech, weakness in the upper or lower limb, sudden amnesia and other symptoms.

In this case, the patient should not hesitate; it is recommended to seek medical help as soon as possible at the neurology clinic of the Yusupov Hospital to obtain a doctor’s consultation. You will undergo the necessary examinations: ultrasound examination of large vessels (first of all, it is necessary to examine the carotid arteries), an electrocardiogram, ECHO-CG, detailed blood tests for the lipid profile and the tendency to form blood clots, the level of homocysteine ​​- an amino acid that causes early atherosclerosis and thrombus formation, as well as several times increasing the risk of stroke and heart attack.

A similar examination is also recommended for patients who have suffered a hypertensive crisis, attacks of angina pectoris (pain in the heart area), or arrhythmia. These conditions often precede a stroke and are manifestations of transient ischemic attacks.

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Diagnostics

Diagnosis of a stroke is quite complex, because to identify the cause and assess brain damage, and therefore the consequences of a stroke, the doctor will need a large amount of data.

To visualize the condition of the brain vessels, CT or MRI can be used, depending on the situation. A fairly informative study on the state of blood flow will be angiography - an X-ray examination using a contrast agent injected into the vessels.

In addition, the doctor may prescribe blood and urine tests; test for glucose and cholesterol levels; conduct an ultrasound examination.

Causes

There are several reasons for the development of a recurrent stroke, including factors beyond a person’s control that provoke the development of a recurrent stroke:

• Patient's age
• Hypertonic disease,
• Alcohol, drug addiction, smoking,
• Poor nutrition
• Failure to follow doctor's recommendations
• Stress,
• Obesity,
• Sedentary lifestyle,
• High cholesterol levels
• Increased irritability
• Diseases of the cardiovascular system,
• Improper work and rest schedule, night shifts, disturbed sleep,
• Diabetes.

The most common type of vascular disorder is ischemic stroke, which accounts for up to 85% of cases. This type of stroke is caused by blockage of blood vessels supplying the brain or their critical narrowing.

The development of ischemic stroke is caused, first of all, by a person’s destructive lifestyle, which means: alcohol abuse, heavy smoking, poor diet, physical inactivity (lack of physical activity). Such habits lead to a deficiency of oxygen in the brain, associated with inadequate heart function, the loss of the vessels’ elasticity and ability to expand, due to which the blood flow increases, which is necessary for the normal functioning of the central nervous system.

Repeated ischemic stroke occurs due to a number of main reasons:

• psychological and emotional stress;
• excessive stress, heavy physical labor (most often, relapses occur during the summer season, if the patient spends a long time in an uncomfortable position, upside down, and also under the scorching sun, as a result of which dehydration occurs, increasing the risk of vascular accident);
• deterioration in quality of life;
• deterioration of the environmental situation;
• indifferent attitude towards one’s own health (neglect of prevention, poor lifestyle).

Symptoms and consequences

The symptoms of a second stroke are not always the same as those of the first stroke, and they are sometimes quite difficult to determine. Therefore, at the first manifestations of discomfort, it is advisable to turn to professionals - to the neurology center of the Yusupov Hospital, where the patient will quickly undergo a comprehensive examination and be prescribed immediate treatment, thereby minimizing the risk of developing severe complications. Our specialists will organize transportation of the patient to the hospital.

The main symptoms that should cause alarm in a patient who has previously suffered a first stroke:

• the muscles of the face, body or limbs become paralyzed or numb;
• vision deteriorates sharply, vision decreases, blindness occurs;
• speech abilities are impaired;
• consciousness is disturbed: slight drowsiness is felt, fainting occurs, coordination of movements is impaired;
• Nausea and vomiting occur.

The severity of the attack depends on the volume of the affected part of the brain and the location of the affected area. Among the likely consequences of repeated ischemic stroke in the absence of adequate medical care are the following:

• loss of control over the senses;
• loss of ability to think;
• impairment or loss of motor function;
• death (in patients who have suffered a recurrent ischemic stroke, survival is significantly reduced).

Patients suffer a repeated ischemic stroke much more severely than the first, and it is sometimes impossible to predict what consequences it will accompany. In some cases, the nature of the resulting pathologies becomes irreversible. Therefore, the main role belongs primarily to stroke prevention.

Survival rates

It is impossible to give a definite answer to the question of how long people live after a stroke. This figure depends on a large number of factors that cannot be calculated. To characterize life expectancy, doctors use two indicators: survival and mortality. The first characterizes the percentage of people who live longer than a specific period (month, year, 5, 10 years), the second - the percentage of deaths for a specific period.

This figure is very variable. For example, Russian patients die 4 times more often than residents of the United States and developed European countries. Even within the territory of one country, the mortality rate can vary greatly from region to region.

According to a large-scale study of 2009-2010, the highest percentage of mortality was registered among residents of the Stavropol Territory - 44.9%, the lowest - among patients in the Krasnoyarsk Territory - 10.9% (1).

The most critical period is considered the first month after a brain stroke. 15-25% of patients die from ischemic stroke in the first 30 days, and 40-60% from hemorrhagic stroke. With a long-term forecast, this difference smooths out a little.

Survival rates for various forms of apoplexy are shown in the table.

First aid

When the first symptoms of a stroke appear:

• Place the patient on the bed.
• Call an ambulance.
• Place the patient on his back or side if vomiting begins or he loses consciousness.
• Unfasten clothes and belt.
• Open the window to allow fresh air into the room.
• Place a cold wet towel or ice in a bag wrapped in cotton cloth on your head.
• Measure the patient’s blood pressure, pulse, and monitor blood pressure and breathing until the doctors arrive.
• If necessary, give medications that were previously prescribed by the attending physician.
• Constantly talk to the patient, try to get answers to questions from him, and do not lose contact.

Forecast

As is already known, the five-year survival prognosis is disappointing. Loss of intellectual and motor abilities after a second stroke can be lifelong. Most patients after a relapse suffer from irreversible changes and pathologies in the cerebral cortex.

After lesions, patients usually experience disability. In more than half of patients, after suffering a recurrent stroke, a coma occurs, which does not allow the doctor to give a positive prognosis about recovery from it.

Rehabilitation of patients after repeated ischemic stroke in the neurology clinic of the Yusupov Hospital is based on traditional, latest and original methods for the recovery of patients who have suffered a stroke.

Thanks to the extensive practice and rich knowledge of the clinic’s specialists in the field of rehabilitation medicine, comprehensive rehabilitation of patients is carried out at the highest level, meeting international standards.

For optimal rehabilitation, patients are provided with comfortable conditions of stay: cozy rooms, good nutrition and attentive attitude of the staff.

Call by phone and the coordinating doctor will answer all your questions.

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Left or right stroke: which is better?

The key point that determines the prognosis is the timeliness and completeness of medical care. Researchers have found that people who have had a stroke on the left side have a longer life expectancy on average.

The identified pattern is associated with a more difficult diagnosis of right-sided disorders of the blood supply to the brain, which is not accompanied by speech impairments - the main sign that others pay attention to. Also, most people are right-handed, so the loss of functionality of the “working” hand is more noticeable to strangers. When the right side is affected, the more inconspicuous left arm is paralyzed. Qualitatively, life after a stroke worsens equally when both halves of the brain are affected.

Life after ischemic stroke

If the patient experiences an acute period of stroke, then residual disorders are possible in the form of:

• complete immobilization;
• paralysis on one side of the body;
• partial paralysis of a limb;
• paresthesia (numbness with loss of skin sensitivity);
• speech and swallowing disorders;
• vestibular disorders;
• hearing loss;
• pelvic paralysis with inability to control bowel and bladder movements;
• decreased intelligence;
• changes in psyche and character;
• impossibility of self-service.

Recovery of various impaired functions in patients with ischemic stroke occurs at different rates. Thanks to the use of innovative techniques in the rehabilitation clinic of the Yusupov Hospital, movement disorders go away faster, and it may take longer to restore speech. After discharge from the hospital, patients need support from loved ones and continued rehabilitation under the supervision of specialists from the Yusupov Hospital.

Literature

1. Mancia G. Prevention and treatment of stroke in patients with hypertension. Clin Ther. 2004; 26(5):631-48. 2. Medic V.A. Population morbidity: history, current status and study methodology. – M.: Medicine, 2003. – 512 p. 3. Gusev E.I. The problem of stroke in Russia // Journal of Neurology and Psychiatry named after S.S. Korsakov (STROKE supplement to the journal). 2003; 9:3-7. 4. Sarti C, Rastenyte D, Cepaitis Z, Tuomilehto J. International trends in mortality from stroke, 1968 to 1994. Stroke 2000; 31:1588-601. 5. Skvortsova V.I., Chazova I.E., Stakhovskaya L.V. Secondary prevention of stroke. M.: PAGRI, 2002.-120 p. 6. Kadyrmaeva D.R. Clinical significance of a complex of environmental factors of the population of an industrial city in the spread of acute cerebrovascular accidents. Abstract of dissertation….candidate of medical sciences - 2004.-25 p. 7. Vilensky B.S. Stroke. St. Petersburg: Medical Information Agency, 1995. –288 p. 8. Kaste M. How to improve the quality of medical care for patients with stroke on a nationwide scale? Finnish experience. Journal of Neurology and Psychiatry named after S.S. Korsakov (STROKE supplement to the journal). 2003; 9: 65-68. 9. Yamaguchi T. Current state of the problem of acute ischemic stroke in Japan: results of a nationwide hospital study 1999-2000 // Journal of Neurology and Psychiatry named after S.S. Korsakov (STROKE supplement to the journal). 2003; 9: P. 72-74 . 10. Antonicelli R, Germano G. What is new about stroke prevention? Ital Heart J. 2003; 4(12):958-64. 11. Howard G., Howard VJ Stroke incidence, mortality, and prevalence/The prevention of stroke/edited by Philip B. Gorelick and Milton Alter. The Parthenon Publishing Group, 2002; 1:1-10. 12. ARGUS. Arterial hypertension in people of older age groups. Monograph. –M.: “Medical Information Agency”, 2002.-448 p. 13. Centers for Disease Control. Achievements in public health, 1900-1999:decline in deaths from heart disease and stroke – United States, 1900-1999. Morbid Mortal Weekly Rep. 1999; 48:649-56. 14. Straus SE, Majumdar SR, McAlister FA. New evidence for stroke prevention: clinical applications. JAMA. 2002; 18: (11): 396-8. 15. Wolf PA, D'Agostino RB, Balander AJ, Kannel WB Probability of stroke: a risk profile from the Framingham Study. Stroke. 1991; 22: 312-18. 16. US Census Bureau. Population projections program, population division, US Census Bureau, Washington, DC: 20233, 2001. 17. Howard VJ Howard G., “Nonmodifiable” risk factors for stroke: age, race, sex, and geography/The prevention of stroke/edited by Philip B. Gorelick and Milton Alter. The Parthenon Publishing Group, 2002. Ch. 2. P.-11-20. 18. Shevchenko O.P., Praskurnichy E.A. Prevalence of stroke in the population. The importance of arterial hypertension//Secondary prevention of stroke in patients with arterial hypertension. MOSES results, 2005 19. Chizhevsky A.L. The earth in the arms of the sun. - M.: Eksmo Publishing House, 2004. - 928 p. 20. Melatonin in health and pathology/Edited by F.I. Komarov, S.I. Rapoport, N.K. Malinovskaya, V.N. Anisimov. –M.: Publishing House Medpraktika-M, 2004. –308 p. 21. Hankey GJ, Warlow CP Treatment and secondary prevention of stroke: evidence, costs, and effects on individuals and populations. The Lancet. 1999; 354: 1457-63. 22. Update of American recommendations for the early management of patients with ischemic stroke. Pharmateka. 2005; 17: 66-69. 23. Plavinsky S.L. The end of heroic medicine. Medical Bulletin. 2005; 29: 4. 24. Gavrilova S.I. Pharmacotherapy of Alzheimer's disease. –M.: Pulse, 2003. –320 p. 25. Skvortsova V.I. Rescue algorithm. Medical Bulletin. 2005; 29:9-10.

Prognosis in older people

In patients with ischemic stroke, age is one of the most important factors that influence the prognosis and quality of life after the acute period of the disease. In older people, ischemic stroke is much more severe than in younger patients. Doctors at the Yusupov Hospital take an individual approach to the treatment of elderly patients; when prescribing medications, they use doses recommended for a certain age. When using innovative methods of kinesitherapy, the age characteristics of the body are taken into account.

The prognosis after an ischemic stroke suffered by an elderly person is influenced by the following factors:

• localization of the ischemic focus;
• prevalence of cerebral infarction zone;
• a disease that caused a stroke;
• severity of neurological symptoms.

Coma caused by cerebral edema is the most severe neurological manifestation of a stroke, sharply worsening the prognosis.

Factors that positively influence the results of rehabilitation of elderly patients and improve the prognosis are:

• a small lesion confirmed by computed tomography;
• maintaining the patient's full consciousness;
• minimal number of neurological damages;
• absence of pronounced atherosclerotic changes in blood vessels according to the results of Dopplerography of the arteries of the head and neck;
• the patient's profession requiring constant mental stress;
• normal blood pressure;
• absence of arrhythmias and other heart diseases.

Treatment

A patient with a recurrent stroke most often ends up in the intensive care unit. At the Yusupov Hospital, doctors begin treatment and early rehabilitation immediately after diagnosis. The prognosis is most favorable when patients are admitted to the neurology clinic within the first 4 hours from the appearance of the first signs of acute cerebral circulation. Doctors at the neurology clinic prescribe adequate treatment, thanks to which the nerve cells around the ischemic site completely restore functional activity.

The use of thrombolysis therapy by neurologists at the Yusupov Hospital for elderly patients significantly improves the prognosis. As a thromolytic agent, doctors at the neurology clinic use the most effective drug - tissue plasminogen activator. After the clot dissolves, blood flow through the affected vessels is restored, the supply of oxygen and nutrients to the ischemic area and the area around the cerebral infarction improves. The outcome of ischemic stroke is improved by the use of ancrod (an enzyme from snake venom) in the first 3 hours after the development of acute cerebrovascular accident and for five subsequent days.

To prevent further formation of blood clots and re-embolism, elderly people are given:

• direct anticoagulants (sodium heparin or low molecular weight heparin);
• antiplatelet agents;
• drug from the thienopyridine group Ticlopidine.

If there are contraindications or a high risk of complications from taking these drugs, doctors at the Yusupov Hospital prescribe Clopidogrel to patients. Drugs with neuroprotective and neurometabolic effects improve the plasticity of nerve cells. The tone of cerebral arteries in elderly people increases under the influence of vasoactive drugs.

In elderly people, ischemic stroke often occurs against the background of severe arterial hypertension. During the 7-10 days of the acute period of stroke, cardiologists at the Yusupov Hospital when the patient’s systolic blood pressure is less than 200 mm. rt. Art. do not carry out antihypertensive therapy, since hypotension worsens the oxygen saturation of brain areas susceptible to ischemia. In patients with systolic blood pressure above 200 mm. rt. Art. it is reduced very slowly to numbers of 10 mm. rt. Art. exceeding the pressure to which the patient is adapted. After the acute period, cardiologists select individual antihypertensive therapy.

Our information

Of the 500 thousand strokes that are registered annually in our country, ischemic ones, caused by blockage or narrowing of the vessels supplying the brain, account for the vast majority - 85%.

Hemorrhagic strokes with hemorrhage in the brain or under its membranes as a result of rupture of the vascular wall are much less common - in 10-15% of cases, but are more severe and destructive in consequences. Fortunately, since machines for measuring blood pressure have become a staple in our families, there have been fewer hemorrhagic strokes. And the number of ischemic cases, on the contrary, has increased. Why? There are many mechanisms for the development of ischemic stroke. Among them is a destructive lifestyle with bad habits, poor nutrition and physical inactivity (lack of movement).

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If a person close to you exhibits the signs of transient cerebrovascular accident described above, you should put him or her to bed and measure his blood pressure. If it is above 160 mm Hg. Art., you must definitely call an ambulance and give the patient his usual blood pressure-lowering drug. You can also give aspirin. Simple or soluble is better: medications in special forms that prevent stomach irritation act more slowly.

Rehabilitation

Early rehabilitation significantly improves the prognosis after a stroke. Doctors at the Yusupov Hospital begin to carry out rehabilitation measures from the first day the patient is admitted to the neurology clinic. The intensity of the rehabilitation program depends on the patient’s condition and the degree of his disability. At the Yusupov Hospital, the department for seriously ill patients is equipped with special multifunctional beds. Using the devices of a multifunctional bed, medical personnel can periodically change the patient’s position, carry out hygiene procedures, and care for the patient. Changing your posture helps avoid the formation of bedsores and congestion. To reduce the risk of developing contractures, joint pain, pneumonia, and deep vein thrombosis at the Yusupov Hospital, specialists carry out passive rehabilitation from the first days of treatment.

To improve the prognosis of older people, rehabilitation specialists at the Yusupov Hospital after a stroke use the following innovative methods for restoring impaired functions:

• PNF;
• Voita therapy;
• minor manual therapy;
• Castillo-Morales method;
• kinesio taping;
• Mulligan concept;
• Bobath therapy.

Recovery in a boarding house

Rehabilitation of an elderly person after a stroke at home requires the full-time employment of one of the relatives for the next six months. While the patient is bedridden, he cannot be left at home alone for two reasons: he is helpless and it is necessary to deal with him several times a day. The volume of care is so large and multidirectional that soon the caregiver himself will need support and replacement.

In boarding houses for the elderly, professionals are involved in the rehabilitation of patients. Special equipment is used for treatment. An individual program is developed for each patient. Restoration methods that have been developed over the years produce positive results within a month.

Recommendations after a recurrent stroke

All patients who have suffered a stroke are at risk of relapse of the disease. Doctors at the Yusupov Hospital give recommendations to patients on nutrition and prevention of recurrent stroke:

• Dieting. Refusal of spicy, smoked, fatty and sweet foods, alcohol, caviar, eggs, liver. The menu includes more vegetables, fruits, and grains.
• Rejection of bad habits.
• Refusal of heavy physical labor, night shifts, and work with high psycho-emotional stress.
• Sleep at least 8 hours a day.
• Avoid stressful situations.
• During the rehabilitation period, measure blood pressure every day, after completion of rehabilitation at least 3 times a week.
• Take medications prescribed by your doctor in a timely manner and strictly on time.
• Regularly undergo preventive examinations.
• Do the recommended therapeutic exercises daily.