Brain microstroke: first signs, treatment at home, recovery

Today, a microstroke or ischemic attack is defined as a condition that occurs due to a temporary (transient) disruption of blood flow in any part of the brain and is accompanied by signs of focal neurological dysfunction, as occurs with a stroke. So, in essence, it is a sudden attack, but with quickly passing symptoms.

However, there are still a number of inaccuracies in medical approaches to the criteria for diagnosing a microstroke, and some still consider it to be simply a small focal stroke (a mini-version of a stroke, so to speak). However, everyone agrees that the symptoms of a microstroke are transient.

What is the difference between a stroke and a mini-stroke?

The main differences between stroke and microstroke (transient ischemic attack or TIA) are reflected in the International Classification of Diseases (ICD-10). If stroke with persistent focal brain damage is classified as a disease of the circulatory system (I00-I99), then microstroke - like other transient conditions leading to temporary hypoperfusion of the brain (insufficient blood supply) and cerebral ischemia (delays in blood flow) - is included in the class of diseases of the nervous system (G00-G99). Stroke is included in the block of cerebrovascular diseases with impaired cerebral blood supply (I64), and transient ischemic attack (G45.9), commonly called microstroke, belongs to the subclass of episodic and paroxysmal disorders (G40-G47). Such disorders manifest suddenly, so there are virtually no precursors to microstroke.

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

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

It is also noted that almost every fourth patient who suffered a microstroke on their feet, during an examination conducted after the fact, latent cerebrovascular pathologies or other diseases are detected that manifest themselves in one way or another during an ischemic attack.

Epidemiology

According to statistics from the World Health Organization, 35-40% of people who have had a microstroke eventually experience a stroke. Within the next week, it occurs in 11% of people; within the next five years – in 24-29%. Although different sources provide different data, for example, they claim that a month after a microstroke, almost 5% of patients experience a second or repeated microstroke.

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

At the same time, microstroke in men is diagnosed much more often than microstroke in women. Perhaps the reason is that blood viscosity in men is almost one and a half times higher. However, transient ischemic attacks in women of childbearing age occur more often than in men aged 20 to 45 years, and this is associated with long-term use of hormonal contraception and pregnancy pathologies.

In 80-85% of cases, a transient ischemic attack is provoked by blockage of blood vessels (ischemic microstrokes), in 15-20% - point hemorrhages from cerebral vessels (hemorrhagic microstrokes). And microstroke in young people in 40-50% of cases is hemorrhagic.

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

It is unknown how often microstrokes occur in children, but the incidence of TIA in pediatrics is believed to be no more than two cases per 100,000 children. At the same time, about half of all TIAs in childhood are associated with problems of cerebral blood vessels, a quarter - with the blockage of a vessel by a thrombus due to various cardiac pathologies, and in the same number of cases, an idiopathic attack of transient cerebral ischemia is noted.

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Causes microstroke

All possible causes of microstroke 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 microstroke are distinguished - ischemic and hemorrhagic.

Some neurologists continue to include in the concept of TIA a hypertensive crisis that negatively affects brain function and similar acute forms of encephalopathy associated with high blood pressure. However, despite the similarity of symptoms, this does not correspond to the generally accepted criteria for classifying neurological disorders as paroxysmal conditions.

Among the causes of a transient ischemic attack, defined as an ischemic microstroke, is a sudden narrowing or complete blockage of the lumen (obliteration) of a vessel by an atherosclerotic plaque formed in it. This concerns the arterial vessels of the brain, as well as the arteries supplying the brain with blood (in particular, this may be due to internal stenosis of the carotid artery). In addition, particles of a deteriorating atherosclerotic plaque can enter a small vessel of the brain with the blood flow - during a heart attack.

As with ischemic strokes, the pathogenesis of transient ischemic attack is caused by a local decrease in blood flow to the brain, causing focal neurological symptoms. In addition to vascular narrowing due to atherosclerosis, 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 stagnation and the formation of small clots that close the lumen of the cerebral vessel;
• in case of occlusion of peripheral vessels of the brain by a thrombus from large proximal vessels and other extracranial arteries;
• due to thrombocytosis (increased level of platelets in the blood) and impaired blood clotting;
• with excess levels of lipids and low-density lipoproteins in the blood (hyperlipoproteinemia – a hereditary or metabolic pathology of the endocrine system);
• secondary erythrocytosis, leading to an increase in the number of red blood cells in the blood and an increase in its viscosity.

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

Pathogenesis may also be hidden in the spasm of cerebral vessels caused by disorders of the hemodynamics of the brain due to disturbances in any of the mechanisms of its regulation (neurogenic, humoral, metabolic, etc.).

Hemorrhagic microstroke – due to damage to a small vessel and pinpoint hemorrhage – most often occurs with a sharp increase in blood pressure in people with arterial hypertension and weakened vascular walls due to cholesterol deposition. In this case, the pathogenesis consists of temporary dysfunction of neurons in the area of brain tissue at the site of the formed hematoma. And the nature of the symptoms depends on the localization of the hemorrhage.

By the way, there may also be a microstroke with low blood pressure, the mechanism of development of which is associated with a decrease in the speed of cerebral blood flow (due to decreased tone of the vascular walls), a decrease in the volume of blood in the arterioles of the brain, as well as an increase in the difference in oxygen content in arterial and venous blood.

How a mini-stroke occurs in a dream can only be guessed at: the neurological symptoms of TIA that may occur in a sleeping person do not necessarily make him wake up. And by the time of awakening, all signs disappear.

And when a microstroke occurs 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 microstroke during pregnancy, in addition to 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 period of gestation).

Reversibility of neurological symptoms in microstrokes is most likely ensured by spontaneous lysis or distal passage of the occlusive thrombus or embolus. In addition, restoration of perfusion in the ischemic area occurs through compensation via collateral circulation: by bypass routes - through lateral collateral vessels.

However, brain damage due to short-term hypoxia is still not excluded when multiple microstrokes occur (such as a series of ischemic attacks) or an extensive microstroke affecting several areas at once.

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Risk factors

The main risk factors for microstrokes are considered to be:

• uncontrolled arterial hypertension and hypertension;
• hypercholesterolemia (high blood cholesterol) and atherosclerosis;
• age over 55 years;
• family history of TIA and stroke;
• hematological diseases or changes in blood composition due to dietary characteristics (for example, an increase in the level of homocysteine in the blood, which is formed when consuming large amounts of animal proteins and reduces the elasticity of blood vessels);
• thrombophlebitis of the lower extremities;
• diabetes mellitus;
• history of cardiovascular disease;
• occlusion or stenosis of the carotid artery supplying the brain;
• smoking and alcohol abuse.

Risk factors for ministroke in children include abnormalities of the cerebral blood vessels and congenital heart defect, blood clotting problems, certain viral infections, hemolytic anemia, and long-standing low blood pressure.

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Symptoms microstroke

When asked whether a microstroke can go unnoticed, neurologists give a positive answer, explaining this by the short duration of the symptoms. Often, the first signs of a transient ischemic attack - causeless general weakness and dizziness - become its only symptoms. Although the options for neurological signs of this paroxysmal condition are quite diverse and are determined by both the localization of the cerebral blood supply disorder in a particular patient and its etiology.

Acute pain may occur in the occipital or frontal region of the head during a microstroke. And pressure during a microstroke rises sharply in hypertensive patients and may decrease in hypotensive patients, as well as in those who suffer from VSD and cardiac arrhythmia.

Also, symptoms of a mini-stroke may manifest themselves as:

• a sudden feeling of fatigue that has no external cause;
• a condition close to confusion (loss of consciousness is only possible with ischemia of the thalamus or brainstem, which is quite rare);
• paresthesia (numbness and tingling of the limbs or face);
• weakness on one side of the body (hemiparesis), contralateral paresis (partial paralysis of the arm or leg on the side opposite the affected hemisphere of the brain);
• deterioration of coordination of movements (ataxia);
• ocular ischemic syndrome - a temporary decrease in visual acuity in one eye or the appearance of spots of light before the eyes;
• speech difficulties (aphasia, dysphagia);
• tinnitus and hearing loss;
• decreased ability to concentrate (short-term distraction).

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

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

In the previously mentioned carotid artery syndrome, the symptoms of TIA are usually unilateral and most often affect the motor area of the cerebral cortex, causing weakness of an arm, leg, or one side of the face; dysphasia may occur (in case of ischemia of Broca's area). Rapidly transient unilateral vision loss is also possible, but this is not a microstroke of the eye, but a syndrome of transient blindness (G45.3 according to ICD-10), indicating retinal ischemia, which is usually associated with embolism or stenosis of the ipsilateral carotid artery.

When blood flow in the basilar artery of the brain and the vertebral arteries is impaired, neurological symptoms such as sudden dizziness, nausea and vomiting; weakness in the limbs and ataxia; temporary unilateral hearing loss; double vision; dysphagia are observed.

Right-sided microstroke may manifest itself as headache and dizziness; hypoesthesia (loss of sensation on the left side of the body); left-sided paresthesia and hemiparesis; ataxia; problems with speech and its perception (with ischemia of Wernicke's area); impaired spatial orientation.

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

A microstroke of the cerebellum manifests itself as acute pain in the back of the head, fainting, tremors of the limbs (and sometimes the whole body), loss of balance, unsteadiness of gait, difficulty swallowing and dry mouth, short-term hearing loss and slurred speech.

Complications and consequences

After a microstroke or ischemic attack, certain consequences and complications may arise.

For example, memory loss after a TIA means that the patient does not remember what happened to them and may not understand why they ended up in the hospital. A study of cognitive impairment after TIA in North American clinics found that a third of patients aged 45-65 years (without a history of stroke or dementia) had mild impairment in cognitive domains within three months after a TIA. The greatest declines were in working memory, speed of perception of new information, and attention.

In most cases, speech impairment after a microstroke goes away like hearing and vision impairment. But a person may experience minor muscle weakness on one side of the body, especially if there was a repeated microstroke. Some people experience dizziness and headaches after a microstroke.

Certain changes may manifest in the emotional sphere and affect a person’s behavior after a microstroke, for example, the level of anxiety, irritability, and depression may increase.

Why is a mini-stroke dangerous? Although TIA symptoms disappear in less than a day, one in twelve patients will have a stroke within a week.

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

Scores range from 0 to 7, with higher scores indicating a higher risk of stroke. Risk factors include: age 60 or older; blood pressure of 140/90 mmHg or higher; mild speech impairment after the TIA or one-sided muscle weakness; symptoms lasting more than 55 minutes, and TIA with diabetes. Two points are added if symptoms last 60 minutes or more, and one point is added if diabetes is present.

Urgent action should be taken within 24 hours of symptom onset when the ABCD2 score is 4 or more.

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Diagnostics microstroke

The main problem with diagnosing a mini-stroke is that the symptoms usually regress by the time of examination.

But for a full diagnostic examination, a description of the symptoms is not enough, and blood tests are required: general, biochemical (including the level of platelets, erythrocytes, 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 (hemorrhagic microstroke on MRI will give a clear picture of a point hemorrhage, and in the case of ischemic TIA, the localization of the vessel occlusion 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) there is an ischemic focus in the corresponding area of the brain. However, it is still recommended to diagnose a transient ischemic attack, and not an ischemic stroke.

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Differential diagnosis

Because TIA symptoms quickly resolve, differential diagnosis of microstroke is a difficult task, since similar symptoms occur in cardiac arrhythmia, arterial hypotension, focal epileptic seizures, hypoglycemia, intracranial tumor or subdural hematoma, demyelinating diseases, cephalgic syndrome in thyrotoxicosis or hypothyroidism, pheochromocytoma (adrenal tumor), etc.

Treatment microstroke

Treatment for microstroke is aimed at preventing future strokes. Therapy regimens include medications to control high blood pressure, lower cholesterol (in atherosclerosis) and blood sugar (in diabetes). And for cardioembolic TIAs, drugs against blood clots (antiplatelet agents) are used.

You can take Aspirin, or you can take Dipyridamole (other trade names: Curantil, Anginal, Corozan, Dirinol), which not only reduces the risk of thrombus formation, but also helps to reduce blood pressure, improve the main cerebral and collateral circulation. The recommended dosage of the tablet form of the drug is 25 mg three times a day.

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

To normalize high blood pressure, Captopril can be used for microstroke - one tablet (25 mg) twice a day. However, among the side effects of this drug are headaches, dizziness, tinnitus, nausea and vomiting, hyperthermia, as well as numbness of the limbs and the risk 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, Cardilopine) or Cardosal (Olmesartan medoxomil). See also - Tablets for high blood pressure

The drug Vinpocetine (Cavinton) in injection solution and tablets improves blood supply and oxygen saturation of brain areas that have undergone an ischemic attack; the drug acts not only as a vasodilator, but also improves the rheological properties of the blood. Most often, Vinpocetine and glucose are used as IV drips for microstroke (in the absence of severe arrhythmia, coronary heart disease and acute hemorrhage). Drip administration of the antihypoxant Mexidol (Elfunate) can be prescribed - up to three times a day.

To activate metabolism in the central nervous system, neurologists prescribe Pyrithione (Cerebol, Encephabol) - 0.2 g two to three times a day (for one to three months). Its possible side effects: headache, feeling of fatigue, itchy skin with rashes, nausea, vomiting, bile stasis in the liver, loss of appetite, pain in muscles and joints. Glycine is used for the same purpose in microstroke.

Nootropics and psychostimulants may be prescribed: Piracetam, Eurysam, Citicoline (Ceraxon, Cebroton, Neuraxon, etc.), Calcium hopantenate, gamma-aminobutyric acid preparations (Aminolone, Ganevrin, Encephalon, etc.). Vitamins B1, B12, B15 are also recommended.

Although some medical recommendations after a microstroke do not have solid empirical data, most doctors believe that physiotherapy with electrophoresis (with nootropic drugs) or diadynamic therapy is necessary to activate metabolism in brain tissue. Therapeutic massage for a microstroke is also useful.

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

Surgical treatment may be required - removal of the atherosclerotic plaque that has blocked the lumen of the vessel by two-thirds. In extreme cases, a section of the carotid artery is replaced or stented (this operation carries a potential complication that causes a stroke).

First aid for microstroke

When symptoms of focal neurological dysfunction caused by a transient ischemic attack appear, first aid for a microstroke is required.

Be sure to call an ambulance (stating the exact time when the symptoms began) or quickly take the person to the nearest medical facility. When a person feels ill on the street, you should find out if he or she has diabetes, and if so, give him or her a glucose tablet or a glass of sweet drink (to quickly raise the blood sugar level).

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

You should also ask the person to raise both arms or squeeze your hand tightly (this can reveal arm weakness). If left arm weakness is detected, the person should be turned onto the right side (and vice versa) to allow gravity to direct blood to the affected hemisphere of the brain.

The rest is up to doctors, whose job is to avoid a delay between the onset of symptoms and their diagnosis. Because PLAT, a recombinant tissue plasminogen activator (Alteplase, Reteplase, Tenecteplase), must be used within the first three hours of the onset of ischemic attack signs. By catalyzing the process of converting plasminogen into plasmin, the main enzyme responsible for clot destruction, PLAT helps break down blood clots in vessels. But it is not used in the case of hemorrhagic microstroke and stroke (which require anticoagulants).

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Treatment of microstroke at home

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

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

As usual, herbal treatment includes the use of decoctions of ginkgo biloba leaves, hawthorn and rose hips, and green tea. To strengthen the walls of capillaries, a decoction of St. John's wort is recommended (contraindicated in secretory pathologies of the stomach and gallstones). Hypertensive patients benefit from decoctions and infusions of marsh cudweed and creeping tribulus, as well as figs (or eating their fruits). With a tendency to form blood clots, medicinal plants such as sweet clover (aerial part) and dioscorea (root) help.

See also - How to lower blood cholesterol without medication?

Recovery and rehabilitation after a microstroke

The rehabilitation needs after ischemic attacks are difficult to assess due to the lack of available tools to detect subtle neurological impairments. However, since there may be complications of TIA, rehabilitation after microstroke is carried out.

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

It is necessary to make significant changes in nutrition after a microstroke: reduce the amount of fats, proteins and salt in the diet, increase the consumption of foods with a high fiber content. Also, the diet for a microstroke - if the body weight is above normal - should be less caloric. More details in the publication - Diet for a stroke

Researchers have found that a modified version of cardiac rehabilitation is effective in reducing some of the residual effects of transient ischemic attack (TIA). In particular, it can take advantage of the benefits of spa treatment.

In Ukraine, you can choose sanatoriums for recovery after a microstroke:

• Clinical sanatorium of neurological profile "Avangard" (Nemirov, Vinnytsia region);
• sanatorium "Birch Grove" (Khmelnik, Vinnytsia region);
• Clinical sanatorium "Berdyansk" (Berdyansk, Zaporozhye region);
• Sanatorium "Arctic" (Berdyansk, Zaporozhye region);
• "Lermontovsky" (Odessa);
• "White Acacia" (Odessa);
• "Golden Niva" (Sergeevka settlement, Odessa region);
• Clinical sanatorium "Roshcha" (Pesochin settlement, Kharkiv region);
• sanatorium-preventorium "Solnechny" (Verbki village, Pavlograd district, Dnepropetrovsk region);
• "Ostrech" (Mena, Chernihiv region);
• Sanatorium center "Denishi" (Denishi village, Zhitomir region);
• sanatorium “Chervona Kalina” (Zhobryn village, Rivne region);
• sanatorium "Medobory" (Konopkivka village, Ternopil region);
• Sanatorium "Moshnogorye" (Budyshche village, Cherkasy region).

Prevention

The threat of stroke should motivate those who have had a TIA to change their lifestyle after a microstroke and pay attention to secondary prevention.

And in this regard, patients have many questions. For example, is it possible to work after a microstroke, go to a bathhouse after a microstroke, or fly on an airplane? Is sports possible after a microstroke, as well as sexual activity and sex after a microstroke. And, of course, is alcohol possible after a microstroke?

What do doctors say? Visiting a bathhouse (without spending a long time in the steam room) is possible with normal blood pressure, if there were no recurrences within a month after the first attack. Regarding work: millions of people continue to work after a microstroke, but in some cases they had to change jobs to reduce the workload. Very similar recommendations are regarding intimate life after a microstroke. As for air travel, if you feel well, you can hit the road (taking the necessary medications with you).

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

Prevention itself begins with quitting smoking and drinking alcohol. In addition, you need to lose excess weight, eat right (limit sodium in your diet to prevent blood pressure from rising), control diabetes and cholesterol levels in the blood. And morning exercises after a microstroke should become regular.

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

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Forecast

There is no need to perceive every dizziness due to physiologically caused spasm of cerebral vessels as an ischemic attack. But attention to your condition and all its changes can become a guarantee of preventing major health problems.

And how long people live after a microstroke largely depends on a person's attitude to their health. If you suffer a transient ischemic attack on your feet and come to the doctor complaining of symptoms that have already passed, then you are unlikely to be given sick leave for a microstroke. And this is despite the fact that a prognosis regarding the possibility of developing a stroke will definitely be announced. And so that it does not come true - change your lifestyle and live long!