Microinsult of the brain: first signs, treatment at home, recovery

To date, a microinsult or ischemic attack is defined as a condition that arises from a temporary (transient) impairment of blood flow in any part of the brain and is accompanied by signs of focal neurological dysfunction, as is the case with stroke. So, in its essence, this is a sudden attack, but with rapidly passing symptoms.

However, in the approaches of medicine to the criteria for the diagnosis of a micro stroke, there are still a number of inaccuracies, and some still consider it simply a small-focal stroke (so to speak, a mini version of a brainstroke). True, everyone is unanimous in the opinion that the symptoms of a micro stroke are transient.

What is the difference between a stroke and a micro stroke?

The main differences between stroke and micro-stroke (transient ischemic attack or TIA) are reflected in the International Classification of Diseases (ICD-10). If the stroke with persistent focal brain damage is attributed to diseases of the circulatory system (I00-I99), the micro-insult - like other transient states, resulting in temporary hypoperfusions of the brain (insufficient blood supply) and cerebral ischemia (blood flow delays) - entered the class of diseases nervous system (G00-G99). Stroke is part of the cerebrovascular disease block   with cerebral blood flow disorder (I64), and  transient ischemic attack  (G45.9), commonly called microinsult, refers to a subclass of episodic and paroxysmal disorders (G40-G47). Such disorders appear suddenly, therefore, the precursors of a micro-stroke are virtually absent.

As experts note, TIA is characterized by a short manifestation of symptoms: from a few seconds / minutes to an hour. In most cases, as practice shows, the attack lasts less than half an hour. The maximum duration of symptoms of micro-stroke is still considered to be 24 hours, and if during this time the symptoms do not pass, then a stroke is diagnosed. Experts of the American Association of Stroke (ASA), considering TIA as an episode of focal (ischemic) ischemia, the main factor is not the time factor, but the degree of brain tissue damage. This diagnostic criterion was introduced relatively recently - when it became possible to investigate a microstroke on an MRI.

Many neurological consequences of stroke - due to the formation of foci of necrosis of brain cells - are irreversible and make a person disabled, and with a micro stroke, the symptoms quickly regress, and TIA does not lead to fatal disruption of brain cell metabolism and their death. So a permanent disability after a micro stroke can threaten only with frequent repeated ischemic attacks. But even the only such attack on the brain is considered by doctors to be a predictive sign of a full-scale  ischemic stroke  in the future.

It is also noted that almost every fourth patient who underwent a microinsult on his legs during a postexposure exam reveals latent cerebrovascular pathologies or other diseases that somehow manifest themselves during an ischemic attack.

Epidemiology

According to statistics of the World Health Organization, 35-40% of people who underwent a microstroke, eventually face a stroke. Over the next week, it occurs in 11% of people; for the next five years - in 24-29%. Although different sources give different data, for example, they say that a month after a micro stroke, almost 5% of patients have a second or repeated microstroke.

According to the studies conducted in 2007-2010. A group of French neurologists, within the first three months after TIA stroke occurs in 12-20% of patients, a year later - in 18%, and in five years - in 9%.

In this case, the micro-insult in men is diagnosed much more often than the micro-insult in women. Perhaps the reason is that the blood viscosity of men is almost one and a half times higher. However, transient ischemic attacks in women of childbearing age occur more often than in men of the age category of 20 to 45 years, and this is associated with the prolonged use of hormonal contraception and pregnancy pathologies.

In 80-85% of cases, transient ischemic attack provokes vascular blocking (ischemic microinsults), in 15-20% - point outflow of blood from cerebral vessels (hemorrhagic microinsults). And microinsult in young people in 40-50% of cases is hemorrhagic.

On a microstroke in the elderly (after 60 years) account for 82% of recorded and diagnosed cases. In European countries aged 65-75 years, the stroke that occurs after TIA accounts for up to 8% of all deaths in men and 11% in women.

How often the microinsult occurs in children is not known, but the frequency of TIA in pediatrics, presumably, does not exceed two cases per 100,000 children. At the same time, about half of all TIAs in childhood are associated with the problems of cerebral blood vessels, a quarter - with the closure of the vessel with a thrombus due to various cardiological pathologies, and in the same number of cases an idiopathic attack of transient ischemia of the brain is noted.

[1], [2], [3], [4], [5], [6], [7], [8],

Causes of the micro-stroke

All possible causes of micro-stroke in clinical neurology are considered taking into account the pathogenesis of blood flow disorders in the brain. Moreover, depending on the etiology of these disorders, the main types of micro-strokes are ischemic and hemorrhagic.

Some neurologists continue to include in the concept of TIA negatively affecting the function of the brain hypertensive crisis and similar in symptomatic acute forms of encephalopathies associated with elevated blood pressure. However, despite the similarity of symptoms, it does not correspond to the generally accepted criteria for attributing neurological disorders to paroxysmal conditions.

Among the reasons for the transient ischemic attack, defined as an ischemic micro-insult, is a sudden narrowing or complete overlap of the lumen (obliteration) of the vessel formed by an atherosclerotic plaque. This applies to the arterial vessels of the brain, as well as the arteries that supply the brain with blood (in particular, this may be due to internal stenosis of the carotid artery). In addition, the particles of a disrupting atherosclerotic plaque can flow with a blood stream from a small brain vessel - during a heart attack.

As with ischemic stroke, the pathogenesis of transient ischemic attack is due to a local decrease in blood flow to the brain, causing focal neurological symptoms. In addition to narrowing of the vessels during atherosclerosis, the blood flow may slow down or stop:

• due to embolism of the cerebral artery in the presence of atrial fibrillation, when atrial fibrillation causes blood stasis and the formation of small clots covering the lumen of the cerebral vessel;
• with occlusion of peripheral vessels of the brain with a thrombus from large proximal vessels and other extracranial arteries;
• due to thrombocytosis (elevated platelet levels in the blood) and disruption of its clotting;
• at excessive maintenance of lipids and lipoproteins of low density in blood (hyperlipoproteinemia - hereditary or metabolic pathology of the endocrine system);
• secondary erythrocytosis, leading to an increase in the number of erythrocytes in the blood and increase its viscosity.

It should be noted that - despite the allocation among paroxysmal conditions of the syndromes of the vertebrobasilar arterial system (G45.0) and carotid artery (G45.1) - in practice they are often considered as extracranial pathogenetic prerequisites for the occurrence of micro strokes and strokes.

Pathogenesis can also be found in the spasm of cerebral vessels caused by cerebral hemodynamic disorders when any of the mechanisms of its regulation (neurogenic, humoral, metabolic, etc.) are disturbed.

Hemorrhagic microinsult - due to small vessel damage and spot hemorrhage - most often occurs with a sharp increase in blood pressure in people with arterial hypertension and weakened cholesterol deposition by the walls of the vessels. In this case, the pathogenesis is the temporal dysfunction of neurons in the area of the brain tissue at the site of the hematoma formed. And the nature of the symptoms depends on the localization of hemorrhage.

By the way, there may be a micro-insult with low pressure, the development mechanism of which is associated with a decrease in the rate of cerebral blood flow (due to reduced vascular wall tone), a decrease in blood volume in the arterioles of the brain, and an increase in the oxygen content in arterial and venous blood.

As a microstroke passes in a dream, one can only guess: the neurologic symptoms of TIA that can occur in a sleeping person do not necessarily force him to wake up. And by the time of awakening, all the signs are disappearing.

And when there is a microinsult in type I diabetes (insulin-dependent), the main thing is to distinguish it from the neurological manifestations of hypoglycemia, which are very similar to the symptoms of TIA.

Among the causes of microinsult during pregnancy, except for preeclampsia with high blood pressure, possible occlusion of arterial vessels and cerebral venous thrombosis, there is an increase in blood viscosity (especially in the last gestation period).

The reversibility of neurological symptoms in micro-strokes is most likely provided by spontaneous lysis or distal occlusion of an occlusive thrombus or embolus. In addition, the restoration of perfusion in the field of ischemia occurs through compensation through the collateral circulation: along the bypass - through the side vessels-collaterals.

However, brain damage due to short-term hypoxia is not excluded when multiple micro-strokes occur (as a series of ischemic attacks) or an extensive micro-insult affecting several zones at once.

[9], [10], [11]

Risk factors

The main risk factors for micro-strokes are:

• uncontrolled arterial hypertension and hypertension;
• hypercholesterolemia (elevated blood cholesterol level) and atherosclerosis;
• age over 55;
• family history of TIA and strokes;
• hematological diseases or changes in the blood composition due to dietary habits (for example, a rise in the blood level of homocysteine, formed with the use of a large number of animal proteins and reducing the elasticity of blood vessels);
• thrombophlebitis of the lower extremities;
• diabetes;
• cardiovascular diseases in the anamnesis;
• occlusion or stenosis of the brain-supplying carotid (carotid) artery;
• smoking and alcohol abuse.

Risk factors for the development of micro-stroke in children include cerebral blood vessel anomalies and congenital heart disease, blood clotting problems, some viral infections, hemolytic anemia, and long-term low blood pressure.

[12], [13], [14],

Symptoms of the micro-stroke

When asked whether the micro-insult can go unnoticed, neurologists give a positive response, explaining this by the short-term manifestation of symptoms. Often the first signs of a transient ischemic attack - causeless general weakness and dizziness - become its only symptoms. Although the variants of the neurological signs of this paroxysmal state are quite diverse and are caused both by the localization of the violation of the blood supply to the brain in a particular patient, and by its etiology.

In the occipital or frontal region of the head, acute pain can occur with a micro stroke. And the pressure at a micro stroke rises sharply in hypertensive patients and can decrease in hypotensive patients, as well as in those who suffer from VSD and cardiac arrhythmia.

Also, the symptoms of a micro stroke can be manifested:

• without external causes, a sudden sense of fatigue;
• a state close to confusion (a loss of consciousness is possible only with ischemia of the thalamus or brainstem, which is rare enough);
• paresthesia (numbness and tingling of limbs or face);
• weakness on one side of the body (hemiparesis), contralateral paresis (partial paralysis of the arm or leg from the side opposite to the affected hemisphere of the brain);
• deterioration of coordination of movements (ataxia);
• ocular ischemic syndrome - a temporary decrease in the clarity of vision with one eye or the appearance of light spots in front of the eyes;
• verbal difficulties (aphasia, dysphagia);
• noise in the ears and hearing impairment;
• decreased ability to concentrate (short-term absent-mindedness of attention).

Micro-insult and temperature: in 70-72% of cases, temperature values can rise slightly above + 37 ° C; body temperature below physiological norm is most often observed when TIA occurs against hypoglycemia in patients with diabetes mellitus.

Transient global amnesia (transient paroxysmal disorder with code G45.4), often regarded as memory loss after a microstroke, is extremely rare and only with temporary hypoperfusion in the medial temporal lobes of the cerebral cortex.

In the carotid artery syndrome mentioned earlier, the symptoms of TIA are usually unilateral and most often affect the motor region of the cortex, causing weakness in the arm, leg, or one side of the face; can be dysphasia (with ischemia of the Broca zone). One-sided vision loss is also possible, but this is not a microinsult of the eye, but a syndrome of transient blindness (G45.3 in ICD-10), indicative of retinal ischemia, which is usually associated with embolism or stenosis of the ipsilateral carotid artery.

When the blood flow in the basilar artery of the brain and vertebral (vertebral) arteries is disturbed, neurologic symptoms such as sudden dizziness, nausea and vomiting are observed; weakness in the extremities and ataxia; temporary one-sided hearing impairment; double vision in the eyes; dysphagia.

A right-sided micro-insult can be manifested by headache and dizziness; hypoesthesia (loss of sensitivity by the left side of the body); left-sided paresthesia and hemiparesis; ataxia; problems with speech and its perception (with ischemia center Wernicke); violation of spatial orientation.

Possible symptoms that differentiate the left-sided microstroke include right-sided hypoesthesia, paresthesia and hemiparesis; Inadequacy of the logical and emotional perception of the environment (there may be a feeling of anxiety and fear).

The microinsult of the cerebellum manifests itself as acute pain in the neck, fainting, tremor of the limbs (and sometimes the whole body), loss of balance, gait unsteadiness, difficulty swallowing and dry mouth, short-term loss of hearing and indistinct pronunciation.

Complications and consequences

After a micro-stroke or ischemic attack, certain consequences and complications may occur.

For example, memory loss after a micro stroke is manifested in the fact that the patient does not remember what happened to him, and may not understand why he was in the hospital. In a study of cognitive impairment after TIAs conducted in clinics in North America, it was found that a third of patients aged 45-65 years (without a history of stroke or dementia) experienced mild violations of cognitive domains within three months after the microstroke. At the same time, working memory, speed of perception of new information and attention decreased most of all.

In most cases, speech disorders after a micro stroke go through as a violation of hearing and sight. But, perhaps, a person will experience a slight muscle weakness on one side of the body, especially if there was a repeated microstroke. Some people experience dizziness and headache after a micro stroke.

Certain changes can manifest themselves in the emotional sphere and affect the behavior of a person after a micro stroke, for example, the level of anxiety, irritability, depressiveness may increase.

What is dangerous microinsult? Although the symptoms of TIA disappear in less than one day, one in 12 patients has a stroke within a week.

The risk of stroke after transient attacks of cerebral ischemia is assessed by specialists on the ABCD2 scale, which takes into account: age, blood pressure, clinical data, duration of symptoms, presence or absence of diabetes.

Estimates range from 0 to 7, with higher scores indicating a higher risk of stroke. Risk factors include: age 60 years and older; level of arterial pressure 140/90 mm Hg. Art. Or higher; a slight speech disorder after a micro stroke or one-sided muscle weakness; the duration of symptoms is more than 55 minutes, as well as a microstroke in diabetes. With a duration of symptoms of 60 or more minutes, two points are added, in the presence of diabetes, one point.

Urgent measures should be taken within 24 hours after the onset of symptoms, when the ABCD2 score is 4 or more points.

[15], [16], [17]

Diagnostics of the micro-stroke

The main problem of diagnosing a micro stroke is that the symptoms usually regress at the time of the examination.

And for a full-fledged diagnostic examination, there is little description of the available symptoms, and blood tests are needed: general, biochemical (including platelets, red blood cells, glucose, cholesterol, alkaline phosphatase, thyroid hormones, uric acid, homocysteine). Additional laboratory tests include: detection of hypercoagulation (especially in young patients with unknown vascular risk factors), analysis of cerebrospinal fluid, etc.

Instrumental diagnostics is mandatory:

• CT or MRI of the brain (a hemorrhagic micro-insult on the MRI will give a clear picture of a pinpoint hemorrhage, and with ischemic TIA, the localization of the occlusion of the vessel will be visualized);
• Ultrasound-dopplerography of cerebral vessels;
• echocardiography;
• electrocardiography;
• electroencephalography

In most patients, CT and MRI of the head do not reveal focal changes in TIA, but in 10-25% of cases (more often with a longer manifestation of symptoms), the ischemic focus in the corresponding area of the brain is still present. However, it is recommended to diagnose a transient ischemic attack, rather than an ischemic stroke.

[18], [19], [20],

Differential diagnosis

Because the symptoms of TIA go away quickly, differential diagnosis of the micro-stroke is not an easy task, since similar symptoms are manifested in: cardiac arrhythmia, arterial hypotension, focal epileptic seizures, hypoglycemia, intracranial tumor or subdural hematoma, demyelinating diseases, cephalgic syndrome in thyrotoxicosis or hypothyroidism, pheochromocytoma (adrenal gland tumors), etc.

Treatment of the micro-stroke

Treatment of a micro stroke is aimed at preventing a stroke in the future. The therapy regimen includes medications to control high blood pressure, lower cholesterol (for atherosclerosis), and blood sugar (with diabetes). And with cardioembolic TIA, anti-clotting agents are used (antiplatelet agents).

You can take Aspirin, and you can - the drug Dipiridamol (other trade names - Kurantil, Anginal, Korozan, Dirinol), which not only reduces the risk of thrombosis, but also helps reduce blood pressure, improve the basic cerebral and collateral circulation. The recommended dosage tableted form of the drug - three times a day for 25 mg.

The drug group antiagregantov Clopidogrel (Plavix, Lopirel) is taken one tablet (75 mg) once a day - in combination with Aspirin.

For normalization of elevated blood pressure, CAPTOPRES can be used with a micro stroke - by a pill (25 mg) twice a day. However, side effects of this drug are headaches, dizziness, tinnitus, nausea and vomiting, hyperthermia, as well as numbness of the extremities and the threat of stroke. So, if there are no problems with the kidneys, it is recommended to take Irbesartan (Ibertan) or Teveten (Naviten), as well as Amlodipine (Amlotop, Acridipine, Cardilopin) or Cardosal (Olmesartan medoxomil). See also -  High-pressure tablets

The drug Vinpocetine (Cavinton) in a solution for injection and in tablets improves blood supply and oxygen saturation of parts of the brain that underwent ischemic attack; the drug acts not only as a vasodilator, but also improves the rheological properties of the blood. Most often with Vinpocetin and glucose put droppers with a micro stroke (in the absence of severe arrhythmia, ischemic heart disease and acute hemorrhage). Drip administration of the antihypoxant Mexidol (Elfunata) may be prescribed up to three times a day.

To increase metabolism in the central nervous system, neurologists prescribe Pirition (Cerebola, Encephabol) - 0.2 g two to three times a day (for one to three months). Its possible side effects: headache, fatigue, itching of the skin with rashes, nausea, vomiting, bile stasis in the liver, decreased appetite, pain in the muscles and joints. For the same purpose, Glycine is used in a micro stroke.

Nootropics and psychostimulants can be prescribed: Piracetam,  Eurysam, Citicoline (Ceraxon, Cebreton, Neuraxon, etc.),  Calcium Gopantenate, gamma-aminobutyric acid preparations (Aminalon, Ganevrin, Encephalon, etc.). Vitamins B1, B12, B15 are also recommended.

Although some medical recommendations after a micro-stroke do not have solid empirical data, most physicians believe that physiotherapy with electrophoresis (with nootropic drugs) or diadynamotherapy is necessary to activate metabolism in the brain tissues. Also useful therapeutic massage with a micro stroke.

When a transient ischemic attack is caused by stenosis of the carotid artery,

May require surgical treatment - removal of an atherosclerotic plaque that blocked the lumen of the vessel by two thirds. In extreme cases, the carotid artery is replaced or stenting (this surgery carries a potential complication that causes a stroke).

First aid for micro stroke

When symptoms of focal neurological dysfunction caused by a transient ischemic attack appear, first aid is needed for a micro stroke.

Be sure to call the ambulance (with the message of the exact time when the manifestation of symptoms began) or quickly take the person to the nearest medical institution. When a person has become ill in the street, you should find out if he has diabetes, and in the presence of this disease give a tablet of glucose or a glass of sweet drink (to urgently increase blood sugar).

While waiting for the arrival of medical care, carefully monitor the condition of the person. And to recognize a microstroke or stroke, paramedics recommend asking the person to smile (to check the changes in facial expressions) and repeat the simple sentence (verifying speech disorders).

You also need to ask a person to raise both hands or tighten your hand tight (so you can reveal the weakness of your hands). If weakness of the left arm is revealed, then the person should turn to the right side (and, conversely, vice versa) to allow the force of gravity to direct blood to the affected hemisphere of the brain.

The rest is the business of doctors, whose task is to avoid the delay between the onset of symptoms and their diagnosis. Because PLAT - a recombinant tissue plasminogen activator (Alteplase, Reteplase, Tenecteplase) - is necessary within the first three hours of the onset of signs of ischemic attack. By catalyzing the transformation of plasminogen into plasmin, the main enzyme responsible for the destruction of the clot, PLAT promotes the cleavage of blood clots in the vessels. But it is not used in case of hemorrhagic micro stroke and stroke (in which anticoagulants are necessary).

[21], [22]

Treatment of a micro stroke at home

Home treatment is not suitable in case of severe symptoms of TIA: for this, there simply are no suitable means that affect the pathogenesis of this condition. So, if you have had and passed the symptoms of a micro-stroke, you still need to immediately consult a doctor.

Alternative treatment can be used only as an addition to the complex therapy of hypertension, atherosclerosis and other diseases that increase the risk of cerebral circulatory disorders.

As usual, herbs include the use of decoctions of leaves of ginkgo biloba, hawthorn and hips, green tea. To strengthen the walls of capillaries is recommended decoction of St. John's wort (contraindicated in the secretory pathologies of the stomach and stones in the gallbladder). Hypertonics are useful for decoctions and infusions of crocheted swine and anchorites creeping, as well as figs (or the use of its fruits). With the propensity to form blood clots, such medicinal plants as the clover (aerial part) and dioscorea (root) help.

See also -  How to lower blood cholesterol without drugs?

Recovery and rehabilitation after a micro stroke

The need for rehabilitation after ischemic attacks is difficult to assess because of the lack of available tools to detect little noticeable neurological disorders. But since there may be complications of TIA, rehabilitation after a micro stroke is carried out.

First of all, it is feasible physical exercises after a micro stroke - at least half an hour daily, with a gradual increase in physical activity (after a preliminary examination of the brain vessels, carotid and vertebral) of the arteries).

Substantial changes in food after a micro stroke should be made: reduce the amount of fat, protein and salt in the diet, increase the intake of foods high in fiber. Also, a diet with a micro stroke - if the body weight is above the norm - should be less caloric. More in the publication -  Diet in stroke

The researchers found that a modified version of cardiac rehabilitation is effective in reducing some of the residual effects of transient ischemic attack (TIA). In particular, you can use the possibilities of sanatorium treatment.

In Ukraine, you can choose the sanatorium for recovery after a micro stroke:

• clinical sanatorium of the neurological profile "Avangard" (Nemyriv, Vinnytsia region);
• Sanatorium "Birch Gai" (Khmilnik, Vinnytsia region);
• Clinical sanatorium "Berdyansk" (Berdyansk, Zaporozhye region);
• Sanatorium "Arktika" (Berdyansk, Zaporozhye region);
• "Lermontovsky" (Odessa);
• "White Acacia" (Odessa);
• "Golden Field" (village Sergeevka, Odessa region);
• Clinical sanatorium "Grove" (Pesochin settlement, Kharkov region);
• Sanatorium-preventorium "Solnechny" (Verbky village, Pavlograd district, Dnepropetrovsk region);
• "Ostrech" (Mena, Chernihiv region);
• sanatorium center "Denisi" (Denisi village, Zhytomyr region);
• sanatorium "Chervona Kalina" (Zhobrin village, Rivne region);
• sanatorium "Medobory" (Konopkivka village, Ternopil region);
• sanatorium "Moshnogorye" (village of Budishte, Cherkassy region).

Prevention

The threat of stroke should motivate those with whom TIA happened, change the lifestyle after a micro stroke and pay attention to secondary prevention.

And in this regard, patients have many questions. For example, can I work after a micro stroke, go to the bath after a micro stroke or fly an airplane? Is it possible to have sports after a micro stroke, as well as sexual activity and sex after a micro-stroke. Well, of course, can alcohol after a micro stroke?

What do the doctors answer? Visiting the bath (without a long stay in the steam room) is possible with normal blood pressure, if within a month after the first attack there were no repetitions. Regarding labor activity: millions of people after a micro stroke continue to work, but in some cases they had to change their place of work in order to reduce the workload. Very similar recommendations - concerning an intimate life after a micro stroke. With regard to air travel, then with normal health you can go on the road (taking with you the necessary drugs).

But professional sports, as well as alcohol, are incompatible with those diseases that are a risk factor for cerebral ischemia.

Proper prevention and begins with the refusal of smoking and alcohol. In addition, you need to lose weight, eat right (restrict sodium in the diet, so as not to give rise to arterial pressure), control diabetes and cholesterol in the blood. A morning gymnastics after a micro stroke should be regular.

More information in the article -  How to prevent ischemic stroke?

[23], [24], [25], [26], [27], [28], [29],

Forecast

Do not need every dizziness due to physiologically conditioned spasm of cerebral vessels perceived as an ischemic attack. But attention to your condition and to all its changes can become a pledge to prevent major health problems.

And how much they live after a micro stroke, in many respects depends on the attitude of a person to their health. If you suffer a transient ischemic attack on your legs and come to the doctor with complaints about symptoms that have already passed, then you are unlikely to get sick at a micro stroke. And this despite the fact that it is necessary to sound a forecast about the possibility of developing a stroke. And so that it does not come true - change the way of life and live long!