Dyscirculatory encephalopathy - Symptoms

Symptoms of cerebrovascular insufficiency

The main symptoms of discirculatory encephalopathy are: disturbances in the emotional sphere, polymorphic movement disorders, deterioration of memory and learning ability, gradually leading to maladaptation of patients. Clinical features of chronic cerebral ischemia are progressive course, staging, syndromicity.

In domestic neurology, for quite a long time, initial manifestations of cerebral circulatory insufficiency were attributed to chronic cerebral circulatory insufficiency along with discirculatory encephalopathy. Currently, it is considered unfounded to single out such a syndrome as "initial manifestations of cerebral blood supply insufficiency", given the non-specificity of the presented complaints of an asthenic nature and the frequent overdiagnosis of the vascular genesis of these manifestations. The presence of headache, dizziness (non-systemic), memory loss, sleep disturbance, noise in the head, ringing in the ears, blurred vision, general weakness, increased fatigue, decreased performance and emotional lability in addition to chronic cerebral circulatory insufficiency may indicate other diseases and conditions. In addition, these subjective sensations sometimes simply inform the body of fatigue. If the vascular genesis of asthenic syndrome is confirmed using additional research methods and focal neurological symptoms are identified, the diagnosis of “dyscirculatory encephalopathy” is established.

It should be noted that there is an inverse relationship between the presence of complaints, especially those reflecting the ability to perform cognitive activity (memory, attention), and the degree of severity of chronic cerebral circulatory insufficiency: the more cognitive (cognitive) functions suffer, the fewer complaints. Thus, subjective manifestations in the form of complaints cannot reflect either the severity or the nature of the process.

Cognitive disorders, which are detected already in stage I and progressively increase towards stage III, have recently been recognized as the core of the clinical picture of discirculatory encephalopathy. Emotional disorders (emotional lability, inertia, lack of emotional response, loss of interests), various motor disorders (from programming and control to the execution of both complex neokinetic, higher automated, and simple reflex movements) develop in parallel.

Stages of cerebrovascular insufficiency

Dyscirculatory encephalopathy is usually divided into 3 stages.

• At stage I, the above complaints are combined with diffuse microfocal neurological symptoms in the form of anisoreflexia, convergence insufficiency, and mild reflexes of oral automatism. Mild gait changes are possible (reduced step length, slow walking), decreased stability, and uncertainty when performing coordination tests. Emotional and personal disorders (irritability, emotional lability, anxious and depressive traits) are often noted. Mild cognitive disorders of the neurodynamic type occur already at this stage: slowing and inertia of intellectual activity, exhaustion, fluctuations in attention, and a decrease in the volume of working memory. Patients cope with neuropsychological tests and work that do not require taking into account the time of execution. The patients' vital functions are not limited.
• Stage II is characterized by an increase in neurological symptoms with the possible formation of a mild but dominant syndrome. Individual extrapyramidal disorders, incomplete pseudobulbar syndrome, ataxia, and central type dysfunction of the cranial nerves (proso- and glossoparesis) are revealed. Complaints become less pronounced and less significant for the patient. Emotional disorders worsen. Cognitive dysfunction increases to a moderate degree, neurodynamic disorders are supplemented by dysregulatory ones (frontal-subcortical syndrome). The ability to plan and control one's actions worsens. The performance of tasks that are not limited by time frames is impaired, but the ability to compensate is preserved (recognition and the ability to use hints are preserved). At this stage, signs of reduced professional and social adaptation may appear.
• Stage III is manifested by the presence of several neurological syndromes. Gross gait and balance disorders with frequent falls, pronounced cerebellar disorders, Parkinsonian syndrome, and urinary incontinence develop. Criticism of one's own condition decreases, as a result of which the number of complaints decreases. Pronounced personality and behavioral disorders may appear in the form of disinhibition, explosiveness, psychotic disorders, and apathetic-abulic syndrome. Operational disorders (memory defects, speech, praxis, thinking, and visual-spatial function) join the neurodynamic and dysregulatory cognitive syndromes. Cognitive disorders often reach the level of dementia, when maladaptation manifests itself not only in social and professional activities, but also in everyday life. Patients are incapacitated, and in some cases they gradually lose the ability to care for themselves.

Neurological syndromes in cerebrovascular insufficiency

The most common syndromes identified in chronic cerebral circulatory insufficiency are vestibulocerebellar, pyramidal, amyostatic, pseudobulbar, psychoorganic, and their combinations. Sometimes, cephalgic syndrome is singled out separately. All syndromes characteristic of discirculatory encephalopathy are based on the disconnection of connections due to diffuse anoxic-ischemic damage to the white matter.

In vestibulocerebellar (or vestibuloataxic) syndrome, subjective complaints of dizziness and unsteadiness when walking are combined with nystagmus and coordination disorders. Disorders can be caused by both cerebellar-brainstem dysfunction due to circulatory insufficiency in the vertebrobasilar system and by disconnection of the frontal-brainstem tracts with diffuse damage to the white matter of the cerebral hemispheres due to impaired cerebral blood flow in the internal carotid artery system. Ischemic neuropathy of the vestibulocochlear nerve is also possible. Thus, ataxia in this syndrome can be of 3 types: cerebellar, vestibular. frontal. The latter is also called gait apraxia, when the patient loses locomotion skills in the absence of paresis, coordination, vestibular disorders, sensory disorders.

Pyramidal syndrome in cerebrovascular insufficiency is characterized by high tendon and positive pathological reflexes, often asymmetrical. Paresis is not pronounced or absent. Their presence indicates a previous stroke.

Parkinson's syndrome in the context of discirculatory encephalopathy is represented by slow movements, hypomimia, mild muscle rigidity, more often in the legs, with the phenomenon of "counteraction", when muscle resistance involuntarily increases when performing passive movements. Tremor is usually absent. Gait disorders are characterized by a slowdown in walking speed, a decrease in the step size (microbasia), a "sliding" shuffling step, small and fast stamping on the spot (before starting to walk and when turning). Difficulty in turning while walking is manifested not only by stamping on the spot, but also by turning the whole body with a violation of maintaining balance, which can be accompanied by a fall. Falls in these patients occur with propulsion, retropulsion, lateropulsion phenomena and can also precede walking due to a violation of locomotion initiation (the symptom of "stuck legs"). If there is an obstacle in front of the patient (a narrow door, a narrow passage), the center of gravity shifts forward, in the direction of movement, and the legs stamp on the spot, which can cause a fall.

The occurrence of vascular parkinsonian syndrome in chronic cerebral circulatory failure is caused by damage not to the subcortical ganglia, but to the corticostriatal and corticosteal connections, therefore treatment with drugs containing levodopa does not bring significant improvement to this group of patients.

It should be emphasized that in chronic cerebral circulatory insufficiency, motor disorders manifest themselves primarily as gait and balance disorders. The genesis of these disorders is combined, caused by damage to the pyramidal, extrapyramidal and cerebellar systems. Not the least important is the disruption of the functioning of complex motor control systems, provided by the frontal cortex and its connections with the subcortical and stem structures. When motor control is damaged, dysbasia and astasia syndromes (subcortical, frontal, frontal-subcortical) develop, otherwise they can be called apraxia of walking and maintaining an upright posture. These syndromes are accompanied by frequent episodes of sudden falls.

Pseudobulbar syndrome, the morphological basis of which is bilateral damage to the corticonuclear tracts, occurs quite often in chronic cerebral circulatory insufficiency. Its manifestations in discirculatory encephalopathy do not differ from those in other etiologies: dysarthria, dysphagia, dysphonia, episodes of forced crying or laughter, and oral automatism reflexes arise and gradually increase. Pharyngeal and palatal reflexes are preserved and even high; the tongue is without atrophic changes and fibrillary twitching, which allows differentiating pseudobulbar syndrome from bulbar syndrome, caused by damage to the medulla oblongata and/or cranial nerves emerging from it and clinically manifested by the same triad of symptoms (dysarthria, dysphagia, dysphonia).

Psychoorganic (psychopathological) syndrome can manifest itself in emotional-affective disorders (asthenodepressive, anxious-depressive), cognitive (cognitive) disorders - from mild mnemonic and intellectual disorders to various degrees of dementia.

The severity of the cephalgic syndrome decreases as the disease progresses. Among the mechanisms of cephalgia formation in patients with chronic cerebral circulatory insufficiency, one can consider myofascial syndrome against the background of osteochondrosis of the cervical spine, as well as tension headache (TH) - a type of psychalgia, often arising against the background of depression.