Treatment of dyscirculatory encephalopathy

The goal of treatment of chronic cerebral circulatory insufficiency is stabilization, suspension of the destructive process of brain ischemia, slowing down of progression, activation of sanogenetic mechanisms of compensation of functions, prevention of both primary and repeated stroke, therapy of basic background diseases and concomitant somatic processes.

Obligatory treatment is considered to be acute (or exacerbated) chronic medical illness, since on this background the phenomena of chronic cerebral circulatory insufficiency increase significantly. They, in combination with dismetabolic and hypoxic encephalopathy, begin to dominate the clinical picture, leading to incorrect diagnosis, non-core hospitalization and inadequate treatment.

Indications for hospitalization

Chronic insufficiency of cerebral circulation is not considered an indication for hospitalization, if its course was not complicated by the development of a stroke or severe somatic pathology. Moreover, hospitalization of patients with cognitive disorders, their removal from the usual situation can only worsen the course of the disease. Treatment of patients with chronic cerebral circulatory insufficiency is entrusted to the out-patient and polyclinic service; if cerebrovascular disease has reached stage III of discirculatory encephalopathy, home care is needed.

Drug treatment of dyscirculatory encephalopathy

The choice of medications is due to the main directions of therapy noted above.

The main directions in the treatment of chronic cerebral circulatory insufficiency are the following two areas of basic therapy: normalization of brain perfusion by affecting different levels of the cardiovascular system (systemic, regional, microcirculatory) and affecting the platelet hemostasis. Both these directions, while optimizing the cerebral blood flow, simultaneously fulfill the neuroprotective function.

Basic etiopathogenetic therapy, which affects the main pathological process, implies, first of all, adequate treatment of arterial hypertension and atherosclerosis.

[1], [2]

Hypotensive therapy

A significant role in the prevention and stabilization of manifestations of chronic cerebral circulatory insufficiency is attributed to the maintenance of adequate blood pressure. In the literature there is information about the positive effect of normalizing blood pressure on the restoration of an adequate response of the vascular wall to the gas composition of the blood, hyper- and hypocapnia (metabolic regulation of blood vessels), which affects the optimization of cerebral blood flow. Retention of blood pressure at the level of 150-140 / 80 mmHg. Prevents the growth of mental and motor disorders in patients with chronic insufficiency of cerebral circulation. In recent years, it has been shown that antihypertensive agents have a neuroprotective property, that is, they protect the surviving neurons from secondary degenerative damage after a stroke and / or chronic cerebral ischemia. In addition, adequate antihypertensive therapy can prevent the development of primary and repeated acute disorders of cerebral circulation, the background for which often becomes chronic cerebral circulatory insufficiency.

Very important is the early onset of antihypertensive therapy, before the development of a pronounced "lacunar state" that determines the dissociation of cerebral structures and the development of basic neurological syndromes of discirculatory encephalopathy. When prescribing antihypertensive therapy, sharp fluctuations in blood pressure should be avoided, as with the development of chronic cerebral circulatory insufficiency, the mechanisms of autoregulation of cerebral blood flow decrease, which will depend to a greater extent on systemic hemodynamics. In this case, the autoregulation curve will shift toward higher systolic blood pressure, and arterial hypotension (<110 mm Hg) - adversely affect cerebral blood flow. In this regard, the prescribed drug should adequately control systemic pressure.

At present, a large number of antihypertensive drugs have been developed and introduced into clinical practice, which make it possible to control blood pressure from different pharmacological groups. However, the obtained data on the important role of the renin-angiotensin-aldosterone system in the development of cardiovascular diseases, as well as the relationship between the angiotensin II content in the central nervous system and the volume of ischemia of the brain tissue, allow for the treatment of arterial hypertension in patients with cerebrovascular pathology, which affects the renin-angiotensin-aldosterone system. These include 2 pharmacological groups - angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists.

Both angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists have not only an antihypertensive but also an organoprotective effect, protecting all target organs suffering from arterial hypertension, including the brain. In PROGRESS studies (the appointment of an inhibitor of the angiotensin-converting enzyme perindopril), MOSES and OSCAR (the use of angiotensin II receptor antagonist eprosartan), the cerebroprotective role of antihypertensive therapy has been demonstrated. Especially it is necessary to emphasize the improvement of cognitive functions against the background of taking these medications, given that cognitive disorders are more or less present in all patients with chronic cerebral circulatory insufficiency and are the dominant and most dramatic disabling factors in the severe stages of dyscirculatory encephalopathy.

According to the literature, the effect of antagonists of angiotensin II receptors on the degenerative processes occurring in the brain, in particular, in Alzheimer's disease, that significantly extends the neuroprotective role of these drugs is not excluded. It is known that in recent years, most types of dementia, especially in old age, are considered as combined vascular degenerative cognitive disorders. It should also be noted the alleged antidepressant effect of angiotensin II receptor antagonists, which is of great importance in the treatment of patients with chronic cerebral circulatory insufficiency, which often develop affective disorders.

In addition, it is very important that angiotensin-converting enzyme inhibitors are indicated to patients with signs of heart failure, nephritic complications of diabetes mellitus, and angiotensin II receptor antagonists are able to provide angioprotective, cardioprotective, and also renoprotective effects.

Antihypertensive efficacy of these groups of drugs increases when combined with other antihypertensive agents, more often with diuretics (hydrochlorothiazide, indapamide). Especially shown is the addition of diuretics in the treatment of elderly women.

Lipid-lowering therapy (treatment of atherosclerosis)

Patients with atherosclerotic lesions of the cerebral vessels and dyslipidemia, in addition to diet with restriction of animals and preferential use of vegetable fats, it is advisable to prescribe lipid-lowering drugs, in particular statins (atorvastatin, simvastatin, etc.), which have therapeutic and prophylactic effect. More effective is the intake of these drugs in the early stages of discirculatory encephalopathy. Their ability to reduce cholesterol, improve endothelial function, reduce blood viscosity, stop the progression of the atherosclerotic process in the main arteries of the head and coronary vessels of the heart, have an antioxidant effect, slow the accumulation in the brain of beta-amyloid.

Antiaggregant therapy

It is known that ischemic disorders are accompanied by activation of the platelet-vascular unit of hemostasis, which determines the mandatory prescription of antiplatelet agents in the treatment of chronic cerebrovascular insufficiency. Currently, the most well studied and proven efficacy of acetylsalicylic acid. Apply mainly enteric-soluble forms in a dose of 75-100 mg (1 mg / kg) daily. If necessary, other antiplatelet agents (dipyridamole, clopidogrel, ticlopidine) are added to the treatment. The prescription of this group of drugs has a preventive effect: it reduces the risk of myocardial infarction, ischemic stroke, peripheral vascular thrombosis by 20-25%.

A number of studies have shown that only basic therapy (antihypertensive, antiaggregant) is not always enough to prevent the progression of vascular encephalopathy. In connection with this, in addition to the constant admission of the above groups of drugs, the patient is prescribed course treatment with antioxidant, metabolic, nootropic, and vasoactive agents.

[3], [4], [5], [6]

Antioxidant therapy

As the chronic cerebral circulatory insufficiency progresses, there is an increasing decrease in protective sanogenetic mechanisms, including antioxidant properties of the plasma. In this regard, the use of antioxidants, such as vitamin E, ascorbic acid, ethylmethyl hydroxypyridine succinate, actovegin, is considered pathogenetically justified. Ethyl methyl mercaptopyridine succinate (mexidol) in chronic cerebral ischemia can be used in tablet form. The initial dose is 125 mg (one tablet) 2 times a day with a gradual increase in the dose to 5-10 mg / kg per day (the maximum daily dose is 600-800 mg). The drug is used for 4-6 weeks, the dose is reduced gradually over 2-3 days.

[7], [8], [9], [10], [11], [12]

The use of combined action drugs

Given the variety of pathogenetic mechanisms underlying the chronic cerebral circulatory insufficiency, in addition to the above-mentioned basic therapy, patients are prescribed funds that normalize the rheological properties of blood, microcirculation, venous outflow, which provide antioxidant, angioprotective, neuroprotective and neurotrophic actions. For the exclusion of polypharmacy, preference is given to drugs that have a combined effect, a balanced combination of drugs in which excludes the possibility of incompatibility of drugs. Currently, a fairly large number of such drugs have been developed.

Below are the most common drugs that have a combined effect, their doses and the frequency of application:

• Ginkgo biloba leaves extract (40-80 mg 3 times a day);
• vinpocetine (5-10 mg 3 times a day);
• dihydroergocryptin + caffeine (4 mg twice a day);
• hexabendine + etamivan + etofillin (1 tablet contains 20 mg hexobendine, 50 mg etamivan, 60 mg etofillina) or 1 tablet forte, in which the content of the first 2 drugs is 2 times greater (taken 3 times a day);
• piracetam + cinnarizine (400 mg of niracetam and 25 mg of cinnarizine 1-2 capsules 3 times a day);
• vinpocetine + piracetam (5 mg vinpocetine and 400 mg piracetam, one capsule 3 times a day);
• pentoxifylline (100 mg 3 times a day or 400 mg 1 to 3 times a day);
• trimethylhydrazinium propionate (500-1000 mg once a day);
• nicergoline (5-10 mg 3 times a day).

These drugs are prescribed courses for 2-3 months 2 times a year, alternating them for individual selection.

The effectiveness of most drugs affecting the blood flow and brain metabolism is manifested in patients with early, i.e., stage I and II dyscirculatory encephalopathy. Their use in the more severe stages of chronic cerebral circulatory insufficiency (in the third stage of discirculatory encephalopathy) can give a positive effect, but it is much weaker.

Despite the fact that all of them have the above described set of properties, we can stop at some selectivity of their action, which can make a difference in the choice of the drug taking into account the revealed clinical manifestations.

• Ginkgo biloba leaves extract speeds up the processes of vestibular compensation, improves short-term memory, spatial orientation, eliminates behavioral disorders, and also has a mild antidepressant effect.
• Dihydroergocryptin + caffeine acts primarily at the level of microcirculation, improving blood flow, trophic tissue and their resistance to hypoxia and ischemia. The drug contributes to improving vision, hearing, normalization of peripheral (arterial and venous) circulation, reducing dizziness, noise in the ears.
• Geckobedin + etamivan + etofillin improves concentration of attention, integrative activity of the brain, normalizes psychomotor and cognitive functions, including memory, thinking and working capacity. It is advisable to slowly increase the dose of this drug, especially in elderly patients: the treatment starts with 1/2 tablet a day, increasing the dose by 1/2 tablet every 2 days, bringing it up to 1 tablet 3 times a day. The drug is contraindicated in case of epileptic syndrome and increased intracranial pressure.

Metabolic Therapy

Currently, there is a large number of drugs that can affect the metabolism of neurons. These are preparations of both animal and chemical origin, possessing a neurotrophic action, chemical analogs of endogenous biologically active substances, agents affecting cerebral neurotransmitter systems, nootropics, etc.

Neurotrophic action is possessed by such drugs as cerebrolysin and polypeptides of the cerebral cortex (polypeptide cocktails of animal origin). It should be noted that to improve memory and attention to patients with cognitive disorders due to vascular cerebral pathology, you should enter a fairly large dose:

• Cerebrolysin - 10-30 ml of intravenous drip, per course - 20-30 infusions;
• polypeptides of the cerebral cortex (cortexin) - 10 mg intramuscularly, for the course - 10-30 injections.

Domestic preparations glycine and semax are chemical analogues of endogenous biologically active substances. In addition to their main effect (improvement of metabolism), glycine can produce mild sedative, and semax - an exciting effect, which should be taken into account when choosing a drug for a particular patient. Glycine is a non-essential amino acid that affects the glutamatergic system. Assign the drug at a dose of 200 mg (2 tablets) 3 times a day, the course is 2-3 months. Semax is a synthetic analog of adrenocorticotropic hormone, its 0.1% solution is injected 2-3 drops into each nasal passage 3 times a day, the course is 1-2 weeks.

The concept of "nootropic remedies" unites various drugs that can cause improvement in the integrative activity of the brain, which have a positive effect on memory and learning processes. Pyracetam, one of the main representatives of this group, has these effects only when large doses are prescribed (12-36 g / day). It should be borne in mind that the use of such doses by elderly people can be accompanied by psychomotor agitation, irritability, sleep disturbance, and also provoke an exacerbation of coronary insufficiency and the development of epileptic paroxysm.

Symptomatic treatment of dyscirculatory encephalopathy

With the development of the syndrome of vascular or mixed dementia, background therapy is enhanced by means that affect the exchange of the basic neurotransmitter systems of the brain (cholinergic, glutamatergic, dopaminergic). Cholinesterase inhibitors - galantamine 8-24 mg / day, rivastigmine 6-12 mg / day, modulators of glutamate NMDA receptors (memantine 10-30 mg / day), dopamine agonist D2 / D3 with a2-noradrenergic activity pyribedil on 50-100 mg / day. The last of these drugs is more effective in the early stages of discirculatory encephalopathy. It is important that along with the improvement of cognitive functions, all of the above drugs can slow the development of affective disorders that can be resistant to traditional antidepressants, as well as reduce the severity of behavioral disorders. To achieve the effect of drugs should take at least 3 months. You can combine these tools, replace one another. If the result is positive, you can take an effective medicine or drugs for a long time.

Dizziness significantly worsens the quality of life of patients. Such of the above drugs, like vinpocetine, dihydroergocryptin + caffeine, ginkgo biloba leaf extract, are able to eliminate or reduce the degree of expression of the vertigo. If they are ineffective otoneurologists recommend taking betagistine 8-16 mg 3 times a day for 2 weeks. The drug, along with a decrease in the duration and intensity of dizziness, weakens the severity of vegetative disorders and noise, and also improves coordination of movement and balance.

Special treatment may be required when patients develop affective disorders (neurotic, anxious, depressive). In such situations, antidepressants that do not have anticholinergic action (amitriptyline and its analogs), as well as intermittent courses of sedatives or small doses of benzodiazepines are used.

It should be noted that the treatment unit for groups according to the main pathogenetic mechanism of the drug is rather conditional. For a broader acquaintance with a particular pharmacological means, there are specialized directories, the task of this manual is to determine the directions in treatment.

Surgical treatment of discirculatory encephalopathy

In the occlusal-stenosing lesion of the main arteries of the head, it is advisable to raise the issue of surgical removal of vascular obstruction. Reconstructive surgery is often performed on the internal carotid arteries. This carotid endarterectomy, carotid agency. Indications for their conduct include the presence of hemodynamically significant stenosis (overlapping more than 70% of the diameter of the vessel) or loose atherosclerotic plaque, from which microthrombi can come off, causing thromboembolism of small vessels of the brain.

Approximate terms of incapacity for work

Disability of patients depends on the stage of dyscirculatory encephalopathy.

• At the first stage, patients are able to work. If temporary disability occurs, it is usually caused by intercurrent illnesses.
• II stage of discirculatory encephalopathy corresponds to II-III group of disability. Nevertheless, many patients continue to work, their temporary disability can be caused by both a concomitant disease and an increase in the phenomena of chronic cerebral circulatory insufficiency (the process often proceeds step-by-step).
• Patients with stage III of discirculatory encephalopathy are disabled (this stage corresponds to the I-II group of disability).

[13]

Further management

Patients with chronic insufficiency of cerebral circulation need constant background therapy. The basis of this treatment is the means, correcting blood pressure, and antiaggregant drugs. If necessary, prescribe substances that eliminate other risk factors for the development and progression of chronic cerebral ischemia.

Of great importance are non-drug methods of exposure. These include an adequate intellectual and physical load, feasible participation in social life. With frontal dysbasia with disorders of initiation of walking, congealing, the threat of falls, special gymnastics is effective. Reduction of ataxia, dizziness, postural instability is promoted by stabilometric training, based on the principle of biofeedback. In affective disorders, rational psychotherapy is used.

Information for patients

Patients should follow the doctor's recommendations for both constant and course medication, monitor blood pressure and body weight, stop smoking, follow a low-calorie diet, eat foods rich in vitamins.

It is necessary to conduct recreational gymnastics, use special gymnastic exercises to maintain the functions of the musculoskeletal system (spine, joints), to walk.

It is recommended to use compensatory techniques to eliminate memory disorders, record necessary information, make up a daily plan. You should support intellectual activity (reading, memorizing poems, talking on the phone with friends and relatives, watching television, listening to music or listening to interesting radio programs).

It is necessary to carry out all possible domestic duties, try as long as possible to lead an independent way of life, keep the motor activity with precautionary measures to avoid falling, if necessary use additional means of support.

It should be remembered that in elderly people, after a fall, the degree of cognitive impairment increases significantly, reaching the severity of dementia. To prevent falls, it is necessary to eliminate risk factors for their occurrence:

• remove the carpets for which the patient may hesitate;
• use comfortable non-slip footwear;
• if necessary, rearrange the furniture;
• attach handrails and special handles, especially in the toilet and bathroom;
• the shower should be taken in a sitting position.

Forecast

The prognosis depends on the stage of dyscirculatory encephalopathy. At the same stages, it is possible to assess the rate of progression of the disease and the effectiveness of the treatment. The main adverse factors are pronounced cognitive disorders, often accompanied by an increase in episodes of falling and the risk of injury, such as craniocerebral trauma, and fractures of the limbs (primarily the femoral neck), which create additional medical and social problems.

[14], [15], [16], [17], [18], [19]