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Dyscirculatory encephalopathy: diagnosis
Last reviewed: 23.04.2024
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Diagnosis of dyscirculatory encephalopathy
To diagnose chronic cerebral circulatory insufficiency, it is necessary to establish a connection between clinical manifestations and the pathology of cerebral vessels. For a correct interpretation of the revealed changes, careful collection of an anamnesis with an assessment of the previous course of the disease and dynamic observation of the patients is very important. It should be borne in mind the inverse relationship between the severity of complaints and neurological symptoms and the parallelism of clinical and paraclinical features in the progression of vascular cerebral insufficiency.
It is advisable to use clinical tests and scales taking into account the most common clinical manifestations in this pathology (balance and walking assessment, emotional and personality disorders, neuropsychological testing).
[Anamnesis
When collecting anamnesis in patients suffering from these or other vascular diseases, attention should be paid to the progression of cognitive disorders, emotional-personal changes, focal neurological symptoms with the gradual formation of unfolded syndromes. Identification of these data in patients at risk of developing cerebral circulation or who have already suffered stroke and transient ischemic attacks, with a high probability of possible suspicion of chronic cerebral circulatory insufficiency, especially in the elderly.
From the history it is important to note the presence of coronary heart disease, myocardial infarction, stenocardia, atherosclerosis of the peripheral arteries of the extremities, arterial hypertension with the defeat of the target organs (heart, kidney, brain, retina), changes in the valvular apparatus of the heart chambers, disturbances of the heart rhythm, diabetes mellitus and others diseases.
Physical examination
Conducting a physical examination can reveal the pathology of the cardiovascular system. It is necessary to determine the safety and symmetry of pulsations on the main and peripheral vessels of the limbs and the head, as well as the frequency and rhythm of the pulse oscillations. Blood pressure should be measured on all 4 limbs. Be sure to auscultate the heart and abdominal aorta in order to detect noise and heart rhythm disturbances, as well as the main arteries of the head (neck vessels), which allows to determine above these vessels the noise indicative of the presence of stenosing process.
Atherosclerotic stenosis develops usually in the initial segments of the internal carotid artery and in the bifurcation region of the common carotid artery. This localization of stenoses allows you to hear systolic noise during auscultation of the vessels of the neck. In the presence of noise above the patient's vessel, it is necessary to direct it to duplex scanning of the main arteries of the head.
Laboratory research
The main direction of laboratory research is the specification of the causes of the development of chronic insufficiency of cerebral circulation and its pathogenetic mechanisms. The clinical analysis of blood with reflection of the content of platelets, erythrocytes, hemoglobin, hematocrit, leukocytes with unfolded leukocyte formula is investigated. They study rheological properties of blood, lipid spectrum, blood coagulation system, blood glucose. If necessary, conduct additional tests to exclude specific vasculitis, etc.
Instrumental research
The task of instrumental methods is to clarify the level and severity of the vascular and brain tissue damage, and also to identify background diseases. Solve these problems with the help of repeated ECG records, ophthalmoscopy, echocardiography (according to indications), cervical spondylography (with suspected pathology in the vertebrobasilar system), ultrasound dopplerography of the main arteries of the head, duplex and triplex scanning of extra- and intracranial vessels ).
Structural evaluation of the substance of the brain and cerebrospinal fluidways is carried out using visualizing methods of investigation (MRI). To identify rare etiological factors, non-invasive angiography is performed, which allows to detect vascular anomalies, as well as to determine the state of collateral circulation.
An important place is given to ultrasound research methods, which allow to detect both cerebral blood flow disturbances and structural changes in the vascular wall, which are the cause of stenosis. Stenoses are usually divided into hemodynamically significant and insignificant. If there is a decrease in the perfusion pressure distal to the stenotic process, this indicates a critical or hemodynamically significant narrowing of the vessel that develops when the artery lumen is reduced by 70-75%. In the presence of unstable plaques, which are often detected with concomitant diabetes, hemodynamically significant will overlap the lumen of the vessel by less than 70%. It is due to the fact that with an unstable plaque, it is possible to develop arterio-arterial embolism and hemorrhage into the plaque with an increase in its volume and an increase in the degree of stenosis.
Patients with similar plaques, as well as with hemodynamically significant stenoses, should be referred for consultation to an angiosurgeon to resolve the issue of prompt restoration of blood flow along the main arteries of the head.
We should not forget about asymptomatic ischemic disorders of cerebral circulation, which are detected only when additional methods of examination are used in patients without complaints and clinical manifestations. This form of chronic cerebral circulatory failure is characterized by atherosclerotic lesions of the main arteries of the head (with plaques, stenoses), "mute" cerebral infarctions, diffuse or lacunar changes in white matter of the brain and atrophy of brain tissue in persons with vascular lesions.
It is believed that chronic failure of cerebral circulation exists in 80% of patients with stenosing defeat of the main arteries of the head. Obviously, this indicator can reach an absolute value if an adequate clinical and instrumental examination is performed to identify signs of chronic cerebral ischemia.
Given that in the chronic insufficiency of cerebral circulation first of all white matter of the brain suffers, MRI, rather than CT, is preferred. With MRI in patients with chronic cerebral circulatory failure reveal diffuse changes in white matter, cerebral atrophy, focal changes in the brain.
On MP-tomograms, the phenomena of periventricular leukoareosis (rarefaction, decrease in tissue density), which reflects ischemia of white matter of the brain, are visualized; internal and external hydrocephalus (widening of the ventricles and subarachnoid space), caused by atrophy of the brain tissue. Small cysts (lacunae), large cysts, as well as gliosis can be detected, which testify to previously transferred cerebral infarctions, including clinically "mute" ones.
It should be noted that all listed signs are not considered specific; To diagnose dyscirculatory encephalopathy only according to the visualizing methods of examination is incorrect.
Differential diagnosis of discirculatory encephalopathy
The above complaints, which are typical of the initial stages of chronic cerebral circulatory insufficiency, can also arise in cancer processes, various somatic diseases, be a reflection of the prodromal period or asthenic "tail" of infectious diseases, enter the symptom complex of borderline mental disorders (neurosis, psychopathy) or endogenous mental processes schizophrenia, depression).
Signs of encephalopathy in the form of diffuse multifocal lesions of the brain are also considered nonspecific. Encephalopathy is usually defined by the basic etiopathogenetic sign (posthypoxic, post-traumatic, toxic, infectious-allergic, paraneoplastic, dismetabolic, etc.). Dyscirculatory encephalopathy often has to be differentiated from dismetabolic, including degenerative processes.
Dysmetabolic encephalopathy caused by brain metabolism disorders can be either primary, resulting from a congenital or acquired metabolic defect in neurons (leukodystrophy, degenerative processes, etc.) and secondary, when brain metabolic disorders develop against the backdrop of an extracerebral process. The following variants of secondary metabolic (or dismetabolic) encephalopathy are distinguished: hepatic, renal, respiratory, diabetic, encephalopathy in severe multiorgan insufficiency.
Difficult diagnostics of discirculatory encephalopathy with various neurodegenerative diseases, in which, as a rule, there are cognitive disorders and certain focal neurological manifestations causes great difficulties. These diseases include multisystemic atrophy, progressive supranuclear palsy, cortico-basal degeneration, Parkinson's disease, diffuse Levy disease, frontotemporal dementia, Alzheimer's disease. Differentiation between Alzheimer's disease and discirculatory encephalopathy is not a simple task: often discirculatory encephalopathy initiates subclinical Alzheimer's disease. In more than 20% of cases, dementia in the elderly is mixed (vascular degenerative).
Dyscirculatory encephalopathy must be differentiated from such nosological forms as a brain tumor (primary or metastatic), normotensive hydrocephalus manifested by ataxia, cognitive disorders, impaired control of pelvic functions, idiopathic dysbasia with violation of walking and stability software.
It should be borne in mind the presence of pseudodegmentation (dementia syndrome disappears on the background of treatment of the underlying disease). As a rule, this term is applied to patients with severe endogenous depression, when not only the mood worsens, but motor and intellectual activity also weakens. It was this fact that made it possible to include the temporal factor in the diagnosis of dementia (the preservation of symptoms more than 6 months), since the symptoms of depression by this time are being stopped. Probably, this term can be used in other diseases with reversible cognitive disorders, in particular, with secondary dysmetabolic encephalopathy.