A.Kadykov Dokt. Honey of sciences, the prof., scientific research institute of neurology of the Russian Academy of Medical Science N.Shahparonova Kand. Medical sciences, the Center on studying insulta of Ministry of Health of Russia

Infringements of brain blood circulation, vyzyvaja frustration of a food and supply by oxygen separate parts of a brain, privodjat to development ochagovyh neurologic symptoms: to infringement of movements, rechi, sight, memory etc. On duration of existence ochagovyh nevrologicheskih symptoms of infringement of brain blood circulation conditionally divide na strokes (sharp infringements of brain blood circulation) and on passing narushenija brain blood circulation (abroad use the term “tranzitornye ischemic attacks” is more often). If infringements of movements, speech or sight vosstanavlivajutsja during 24 ch, such infringements of brain blood circulation otnosjat to passing, if frustration last more than 24 ch (and can be restored completely) - to a stroke.

a Fig. 1 Kinds of a stroke

a Fig. 2 Scheme of treatment of a stroke

Epidemiologija a stroke

Annually in the advanced countries sredi each 10 000 population occur 25 - 30 cases of a stroke. From 100 patients insultom 35-40 persons perish in the first 3-4 weeks. Economic losses from insulta in the USA make nearby 30 mlrd dollars a year.

In Russia occurs over 400 thousand insultov, that on number it is equal to the population of an average regional city. Among vyzhivshih at the majority various functional infringements are observed: by the end ostrogo the period almost 80 % of patients have impellent infringements (more often eto parezy various degree of expressiveness), more than for third of patients - speech narushenija.

stroke Kinds

On the development mechanism allocate three vida a stroke:

• ischemic (synonyms: a brain heart attack, a softening a brain) when as a result of corking of a brain vessel or for other reason sharp deficiency blood supplies (ischemia) of a certain site a brain develops;
• gemorragichesky (synonyms: a hemorrhage in a brain, an intrabrain hematoma) when owing to rupture of a brain vessel in a brain blood streams, breaking normal blood circulation of a brain fabric;
• subarahnoidalnoe a hemorrhage - a hemorrhage in podpautinnoe brain space.

On a share of ischemic strokes in srednem 80 % of all strokes, on a share of intrabrain hemorrhages - 17 %, on a share subarahnoidalnyh hemorrhages - 3 % (fig. 1) are necessary.

In those countries where there is objazatelnaja a national program of struggle against an arterial hypertension, along with obshchim decrease in quantity of strokes in population the share intrabrain krovoizlijany, since decreases also. Their basic reason - high arterial pressure. Naprotiv, in developing countries where the health services are inaccessible znachitelnoj to a population part, and in a society level of chronic stress iz-for poverty, unemployment and criminality is great, higher percent gemorragicheskih strokes is observed.

Allocate four basic postinsultnyh the period: Sharp (the first 3-4 weeks), early regenerative (the first 6 months), late regenerative (from 6 till 12 months), rezidualnyj (after 1 year).

a brain Heart attack

the Most frequent reasons ishemicheskogo a stroke (a brain heart attack) are: an atherosclerosis main artery heads (internal sleepy and pozvonochnyh arteries), arterial gipertonija, heart diseases. Illnesses of blood concern more rare reasons (eritremija) koagulopatii, vaskulity. Except such leading factors as ateroskleroz, the arterial hypertension and illnesses of heart, to risk factors razvitija an ischemic stroke concerns the smoking influencing on antitromboticheskie svojstva of a vascular wall, infringement lipidnogo an exchange, adiposity, sugar diabet.

On the development mechanism allocate five osnovnyh subtypes of an ischemic stroke: aterotrombotichesky, in which basis lezhit blood clot education on a place of an atherosclerotic plaque; haemodynamic, voznikajushchy at a combination of two factors: sharp pressure decrease owing to vremennogo deterioration of warm activity and a stenosis (narrowing) of one of magistralnyh head vessels; embolichesky at which emboly from heart or ateroskleroticheskoj plaques of a large vessel with a blood current are transferred in more melkie brain vessels and cork them; hypertensive lakunarnyj a heart attack razvivaetsja against an arterial hypertension for which it is characteristic stenozirujushchee defeat of walls of small arteries (arterioskleroz); gemoreologicheskaja okkljuzija (corking) of brain vessels at increase svertyvaemosti blood and-or at hyperaggregation (the raised ability to slipaniju) trombotsitov.

Aterotrombotichesky and gemodinamicheskie strokes occur at night against decrease arterial davlenija and delays of a current of blood is more often.

Lakunarnyj a heart attack and kardioembolichesky a stroke, on the contrary, develop in the afternoon against physical and emotsionalnogo pressure.

the Basic symptoms ischemic insulta. At a stroke can arise not only ochagovye neurologic simptomy (infringements of movements, speeches, sight, etc.) But also obshchemozgovaja simptomatika in the form of infringements of consciousness, a headache, vomiting. If character and vyrazhennost ochagovyh symptoms depend on a site of the centre of defeat on otnosheniju to functionally significant zones of a brain (to the impellent centre, speech ili to the visual centre), obshchemozgovaja semiology substantially zavisit from the sizes of the centre of defeat and a hypostasis of a brain accompanying it. In bolshinstve cases of an ischemic stroke obshchemozgovaja the semiology is expressed not rezko.

Treatment of an ischemic stroke. Bolnogo with stroke any kind it is necessary to hospitalise immediately in bolnitsu. It is desirable, that it there was a clinic having modern methods obsledovanija: a computer tomography (and-or a magnitno-resonant tomography), angiografiju, nejrohirurgicheskoe branch (or group of neurosurgeons) and reanimatsionnoe branch.

In reanimatsionnoe branch gospitalizirujutsja patients with infringement of consciousness, the vital functions (before vsego breath functions). Other patients are hospitalised in neurologic, and eshche it is better - in specialised angionevrologicheskoe branch with the block intensivnoj than therapy.

To number urgent actions kak for patients with an ischemic stroke, and for patients with a hemorrhage in mozg, concern: breath restoration (air line installation, and at neobhodimosti - artificial ventilation of lungs); at epilepticheskih attacks, chasto arising at patients with a heavy stroke, - intravenous introduction diazepama (relaniuma, seduksena), at repeated spasms and development epistatusa - tiopentala sodium.

Arterial pressure at ishemicheskom a stroke reduce only when it exceeds 180-190 mm rt. st. (sistolicheskoe) and 110 mm hg (diastolicheskoe). Pressure should be reduced ochen cautiously - on 15-20 % from initial size, since. Its sharp decrease mozhet to aggravate a brain ischemia.

the General actions for all vi dov a stroke switch on: maintenance at normal level of breath and warm dejatelnosti, the control of arterial pressure, introduction nazogastralnogo a probe pri swallowing infringement, struggle against dehydration, the control over a status kishechnika and a bladder, care of a skin for the purpose of preventive maintenance prolezhnej.

But can be necessary and special meroprijatija in cases ischemic and gemorragicheskogo strokes. These actions mogut to be spent only t ogda when character of a stroke does not raise the doubts, t. e. When to the patient it is spent brain research, and pri suspicion on an ischemic stroke - angiograficheskoe research of vessels, privedshih to a brain ischemia is computer-tomograficheskoe.

the Primary goals specific lechenija an ischemic stroke in the sharpest period are: restoration krovotoka (at full corking krovosnabzhajushchej arteries) and nejroprotektsija (protection nejronov from structural damages). These problems in full it is possible vypolnit provided that the patient is taken to hospital during first three chasov after stroke first signs, in so-called therapeutic okna.

For blood-groove restoration primenjajut trombolitiki - urokinazu, streptokinazu and fabric the activator plazminogena. Appoint these preparations only after carrying out kopjuterno-tomograficheskogo researches and angiografii, confirmed predpolozhenie about presence of a thrombosis and not later 3 ch from the stroke beginning. The dose tkanevogo the activator plazminogena makes 0,9 mg/kg of weight of a body, a preparation vvoditsja intravenously. Haemorragichesky complications arise on the average at 5 % bolnyh (according to different researchers, this figure fluctuates from 0,7 to 56 %).

nejroprotektornaja therapy napravlena on protection of nervous cages against damage in which result razlichnye the metabolic infringements coming in the first minutes and hours of a stroke. Nejroprotektornymi properties possess:

• postsinapticheskie antagonists glutamatnyh receptors (in a chemist`s network are absent, pass clinical approbation in the large neurologic centres of the world);
• presinapticheskie ingibitory glutamata (lubeluzol);
• antioxidants (emoksipin, alpha tocopherol, karnozin, meksidol);
• blokatory kaltsievyh channels (nimodipin);
• the preparations possessing nootropnym action: nootropil (piratsetam) (in the first days to 12,0 g intravenously kapelno), tserebrolizin (in the first days on 10,0-20,0 g intravenously kapelno), semaks.

“tsitoprotektornoe therapeutic okno” for application of many nejroprotektornyh preparations (for example, for antagonistov glutamatnyh receptors) narrow enough: the first 5-6 ch. After pervyh stroke signs. Nootropy and antioxidants are applied during all ostrogo the stroke period, efficiency of preparations nootropnogo actions (nootropil, piratsetam, semaks, tserebrolizin) and in the regenerative period for uluchshenija kognitivnyh and speech functions is shown.

Irrespective of delivery terms bolnogo with an ischemic stroke (first of all with aterotromboticheskim and kardioembolicheskim), to it haemocorrection is appointed: antiagreganty (aspirin 100 mg in day either tiklid, or dipiridamol (kurantil) and-or anticoagulants. Gemokorrektsija, unlike tromboliticheskoj therapies, it is not calculated on lizis tromba - its problem is preventive maintenance of repeated strokes, increases tromba, a vein thrombosis of the bottom finitenesses and tromboembolii a pulmonary artery.

From anticoagulants of direct action v the sharp period of an ischemic stroke (behind an exception lakunarnogo a heart attack) rekomenduetsja low-molecular geparin (fraksiparin on 7,5 thousand unit 2 times in den within first several days under the control of coagulability of blood). In dalnejshem to the patients who have transferred kardioembolichesky and aterotrombotichesky a stroke, naznachajutsja anticoagulants of indirect action: fenilin or sinkumar, or varfarin under the control protrombina blood.

by the Patient with heavy and average insultom it is spent gemodiljutsija for the purpose of increase cerebral perfuzii and uluchshenija reologicheskih properties of blood. Are used low-molecular dekstrany: reopoligljukin, reomakrodeks. Reopoligljukin it is entered intravenously kapelno in techenie first several (no more than seven) days.

From vazoaktivnyh preparations in ostrejshem the stroke period it is applied trental (intravenously kapelno), eufillin (2,4 % - 10,0 intravenously), kavinton. Efficiency of application in the sharp period insulta such popular vazoaktivnyh means as tsinnarizin, papaverin, nikotinovaja acid, ksantinol/nikotinat is denied by many researchers.

One of serious complications as krovoizlijanija in a brain, and an extensive heart attack of a brain, is the hypostasis of a brain and narastajushchaja an intracranial hypertensia. From medicamentous means of struggle with otekom a brain are applied osmodiuretiki: mannitol which is entered intravenously in techenie 20 minutes in a dose of weight of a body of 0,5-1,0 g/kg, then in upolovinennoj to a dose kazhdye 4-5 days depending on level osmoljarnosti and statuses of function of kidneys; glitserin in the same dose, as mannitol, peroralno (it is possible with juice) everyone 4-5 ch. pervye 3-4 days. Hyperventilation is effective for struggle against a hypostasis of a brain. At infarkte a cerebellum, accompanied increase of a hypostasis, that threatens sdavleniem stvola a brain (where there are vital centres of breath and krovoobrashchenija), trepanation of a back cranial pole is shown dekompressivnaja. Sleduet to notice, that popular in due time kortikosteroidy for reduction oteka a brain at strokes now are not applied.

the Haemorragichesky stroke

the Principal cause intrabrain krovoizlijany is an arterial hypertension. Among other reasons follows otmetit rupture arterial meshotchatoj aneurysms or arteriovenoznoj malformatsii. In the developed countries in connection with active struggle with arterial gipertoniej the tendency to decrease in cases gemorragicheskogo a stroke across the nation is observed.

a Major factor defining tjazhest gemorragicheskogo of a stroke and development obshchemozgovyh of symptoms up to komy, the size of a hematoma is. However and at rather small sizes gematomy, located close to gipofizarno-gipotalamicheskoj areas, javljajushchejsja the centre of all vegetative functions of an organism, can be observed tjazhelye consequences.

For a hemorrhage in a brain in bolshej stepeni, than for an ischemic stroke, are characteristic: expressed obshchemozgovaja simptomatika, including infringement of consciousness and wakefulness level (from oglushennosti, zatormozhennosti to a coma), meningealnye symptoms (similar to that nabljudajutsja at an inflammation of brain covers - a meningitis), and in spinno-brain zhidkosti blood is found out. However almost 30 % of patients with intrabrain krovoizlijaniem do not have obshchemozgovaja semiology, is not present meningealnyh simptomov and blood in a spinno-brain liquid. These are so-called limited gematomy without blood break in zheludochki a brain and subarahnoidalnoe space. Poetomu if the doctor does not have possibility to spend to the patient a computer tomography golovnogo a brain, it sometimes cannot appoint specific to the given kind insulta treatment. It is possible to put the correct lifetime diagnosis only in rezultate the analysis of data of a computer tomography of a brain.

the Basic method of treatment vnutrimozgovyh hemorrhages in volume over 30-40 ml (it can be defined with pomoshchju a computer tomography of a brain) is surgical vmeshatelstvo . At gemorragicheskom a stroke are spent also already described vyshe actions for struggle against a brain hypostasis, nejroprotektornaja therapy, and at neobhodimosti and reanimatsionnye actions, including artificial ventilation legkih.

Many earlier applied at gemorragichesko m a stroke preparations (such as aminokapronovaja acid) on purpose ostanovki bleedings are not recommended now because of development threat sindroma disseminirovannogo intravascular curling of blood.

subarahnoidalnye hemorrhages

subarahnoidalnye hemorrhages - eto hemorrhages in podpautinnoe brain space. subarahnoidalnye krovoizlijanija there are less often, than heart attacks of a brain and intrabrain krovoizlijanija: their frequency makes from 12 to 16 cases on 100 thousand population ezhegodno. They arise at any age, but more often at the age of 45 - 60 years. Letalnost at their development no more than 20 %.

the Most frequent reason subarahnoidalnogo hemorrhages is rupture arterial meshotchatoj anevrizmy. For subarahnoidalnogo hemorrhages the headache is characteristic sudden very much silnaja ("kinzhalnaja", “have scalded boiled water”), is frequent soprovozhdajushchajasja a pain in a neck, a nausea, vomiting, occasionally consciousness infringement, dezorientirovannostju, epilepticheskimi attacks. Ochagovaja neurologic simptomatika (impellent, speech infringements) in the first days usually is absent. Pri inspection the rspinno-brain liquid is found out expressed meningealnyj a syndrome and krovjanistaja/. The most frequent complication subarahnoidalnogo krovoizlijanija is the vascular spasm accompanied by development of a heart attack mozga. The peak of development of a spasm is necessary for 7-12th day.

In the presence of access to an aneurysm nailuchshim way of treatment subarahnoidalnyh hemorrhages is it hirurgicheskoe removal or its deenergizing from a blood-groove. At the expressed hypostasis mozga and increase of intracranial pressure therapy is spent described above protivootechnaja. For expressiveness reduction angiospazma and preventive maintenance razvitija a brain heart attack the first some days intravenously kapelno are entered nimodipin (nimotop), then within 7-10 days it is accepted inside.

Considering heavy consequences insulta, duration and dearness of treatment, high invalidizatsiju as a result etogo a heavy illness and the huge economic damage put to data zabolevaniem, preventive maintenance of strokes should give much more attention.

Article is published in magazine "Pharmaceutical vestnik"