Treatment of ischemic stroke

The main tasks of the ongoing treatment of ischemic stroke (medical, surgical, rehabilitation) are restoration of disturbed neurological functions, prevention of complications and their control, secondary prevention of recurrent cerebral circulation disorders.

Indications for hospitalization

All patients with suspected acute impairment of cerebral circulation should be hospitalized in specialized departments for the treatment of patients with stroke, with a duration of less than 6 hours - in the intensive care unit (neuroreanimation unit) of these departments. Transportation is carried out on a stretcher with a head raised to 30 °.

Relative restrictions for hospitalization:

• terminal coma;
• dementia in history with severe disability prior to stroke;
• terminal stage of oncological diseases.

Indications for consultation of other specialists

A multidisciplinary approach to the management of a patient with stroke is required, with the coordination of efforts not only of neurologists, but also of specialists of another profile. All patients with stroke should be examined by a therapist (cardiologist), in an emergency order - if there is a suspicion of acute cardiac pathology. It is also necessary to consult an ophthalmologist (examination of the fundus). When revealing the stenoses of the main arteries of the head, more than 60% is indicated by the consultation of the vascular surgeon in order to resolve the question of carotid endarterectomy or stenting of the carotid arteries. With extensive hemispheric cerebral infarction or cerebellar infarction, a neurosurgeon must be consulted to resolve the issue of decompression surgery.

Non-drug treatment

Non-drug treatment of patients with stroke includes measures for the care of patients, evaluation and correction of swallowing function, prevention and treatment of infectious complications (bedsores, pneumonia, urinary tract infections, etc.).

Medication

Treatment of ischemic stroke is most effective in a specialized vascular setting with a coordinated multidisciplinary approach to the treatment of the patient. In the structure of the hospital, which has a specialized department for the treatment of patients with stroke, it is necessary to have an intensive care unit (block) with the possibility of round-the-clock CT, ECG and chest radiography, clinical and biochemical blood tests, ultrasound vascular studies.

The most effective is the beginning of treatment in the first 3-6 hours after the appearance of the first signs of a stroke (the period of the "therapeutic window").

Basal stroke therapy is aimed at correcting vital functions and maintaining homeostasis. It includes monitoring of the main physiological parameters (blood pressure, heart rate, ECG, respiratory rate, hemoglobin saturation of arterial oxygen, body temperature, blood glucose) in the first at least 48 hours after the onset of stroke, regardless of the severity of the patient's condition, and correction and maintenance of indicators of hemodynamics, respiration, water-electrolyte metabolism and glucose metabolism, correction of cerebral edema and increased intracranial pressure, adequate nutritional support, prevention and rbu complications.

In the first week of a stroke, as well as a worsening of the patient's condition, associated with an increase in cerebral edema or a progressive course of atherothrombotic stroke, a routine reduction in blood pressure is unacceptable. The optimal arterial pressure for patients suffering from arterial hypertension will be 170-190 / 80-90 mm Hg, and for patients without arterial hypertension in the anamnesis - 150-170 / 80-90 mm Hg. Exceptions are cases of thrombolytic therapy, a combination of stroke with other somatic diseases that require lowering blood pressure, which in these situations is maintained at a lower level.

With the stabilization of the neurological status, a gradual and cautious decrease in blood pressure can be achieved to values exceeding the patient's usual values by 15-20%.

In case of need to reduce blood pressure, a sharp drop in hemodynamics should be avoided, therefore sublingual administration of nifedipine is unacceptable, and intravenous bolus administration of antihypertensive drugs should be limited. Preference should be given to prolonged forms of antihypertensive drugs.

It is necessary to strive to maintain normovolemia with a balanced electrolyte composition of blood plasma. In the presence of cerebral edema, it is possible to maintain a negative water balance, but only if it does not lead to a decrease in blood pressure.

The main infusion solution in the treatment of patients with stroke is a 0.9% solution of sodium chloride. Hypo-osmolality solutions (0.45% sodium chloride solution, 5% glucose solution) are contraindicated because of the risk of increased edema of the brain. It is also inappropriate to routinely use glucose-containing solutions because of the risk of developing hyperglycemia.

The development of both hypoglycemic and hyperglycemic conditions in patients with stroke is extremely unfavorable. Absolute indications for the appointment of short-acting insulin is the blood glucose level of 10 mmol / l or more. However, the blood glucose content of 6.1 mmol / l is already considered an unfavorable prognostic factor, regardless of the presence or absence of diabetes mellitus in the history.

Patients suffering from diabetes should be transferred to subcutaneous injections of short-acting insulin. Provided that the glycemia is adequately controlled, patients can be excluded in clear consciousness, without aphasic disorders and swallowing disorders, which are able to continue taking glucose-lowering medications and / or insulin according to their usual patterns.

During the first 48 hours all patients with stroke need a constant or periodic percutaneous determination of hemoglobin saturation with arterial oxygen. Indications for further measurement of this and other indicators of oxygen status are determined individually, they depend on the presence of cerebral symptoms, airway patency, gas exchange in the lungs, the state of the gas transport function of the blood.

Routine use of normo- or hyperbaric oxygen therapy for patients with stroke is not shown. However, when hemoglobin is saturated with arterial blood oxygen less than 92%, oxygen therapy is necessary (initial oxygen delivery rate is 2-4 l / min). In parallel with this, it is necessary to take arterial blood to determine the gas composition and acid-base state, as well as to find the causes of desaturation development. With a gradual decrease in the saturation of hemoglobin with arterial oxygen, it is more expedient not to wait for the maximum permissible values, but immediately begin to search for the causes of increasing desaturation.

All patients with a decrease in the level of consciousness (8 points or less on the Glasgow coma scale) show intubation of the trachea. In addition, intubation is indicated with aspiration or a high risk of it with indomitable vomiting and expressed bulbar or pseudobulbar syndrome. The decision on the need for ventilation is based on the basic general resuscitation provisions. The prognosis for patients with stroke who underwent intubation is not always unfavorable.

A decrease in body temperature is indicated with the development of hyperthermia above 37.5 ° C. It is especially necessary to control and correct body temperature in patients with impaired consciousness, since hyperthermia increases the size of the infarct and adversely affects the clinical outcome. It is possible to use NSAIDs (for example, paracetamol), as well as physical methods for lowering temperature (ice on the main vessels and the liver region, wrapping with a cold sheet, rubbing alcohol, using special equipment, etc.).

Despite the significant effect of hyperthermia on the course and outcome of stroke, preventive prescription of antibacterial, antifungal and antiviral drugs is unacceptable. Unreasonable use of antibiotics leads to suppression of growth of sensitive microorganisms and, consequently, reproduction of resistant ones. The emergence in these conditions of an infectious organ damage leads to a regular inefficiency of prophylactically administered antibacterial drugs and dictates the choice of other, usually more expensive antibiotics.

All patients with reduced wakefulness, the presence of clinical symptoms (the symptom of Mondonyzi, Bechterev's zygomatic symptom) or neuroimaging signs of cerebral edema and / or increased intracranial pressure should be in bed with a head raised up to 30 ° (without bending the neck!). In this category of patients, epileptic seizures, coughing, motor agitation and pain should be excluded or minimized. The introduction of hypoosmolar solutions is contraindicated!

With the appearance and / or increase in signs of impaired consciousness due to the development of primary or secondary damage to the brainstem, the administration of osmotic drugs is shown (for other causes of impairment of consciousness, it is first of all necessary to find and eliminate acute somatic diseases and syndromes). Enter mannitol in a dose of 0.5-1.0 g / kg every 3-6 hours or 10% glycerol 250 ml every 6 hours intravenously fast. When these drugs are prescribed, control over the osmolality of the blood plasma is necessary. Introduction of osmotic diuretics with osmolality. Exceeding 320 mosmol / kg, gives unpredictable effect.

As a decongestant, it is possible to use a 3% solution of sodium chloride per 100 ml 5 times per day. To increase the oncotic pressure, you can use an albumin solution (preference should be given to a 20% solution).

The introduction of anti-edema drugs should not be preventative or planned. The appointment of these drugs always implies deterioration of the patient's condition and requires close clinical, monitoring and laboratory monitoring.

Early and adequate nutrition of patients, as well as replenishment of water-electrolyte losses. - an obligatory and daily task of basic therapy regardless of the location of the patient (resuscitation, intensive care unit or neurological department). The development of various violations of swallowing, as well as a violation of consciousness - an indication for the immediate conduct of enteral feeding. Calculation of necessary doses of nutrients is carried out taking into account physiological losses and metabolic needs of the body, especially as the development of ischemia causes hypercatabolic syndrome - hypermetabolism. Inadequate enteral-balanced mixtures require additional administration of parenteral nutrition.

In all cases of stroke such a simple and routine measure as adequate feeding of patients, allows to avoid a lot of complications and ultimately affects the outcome of the disease.

The most frequent complications of a stroke are pneumonia, urological infections, deep vein thrombosis of the lower leg and thromboembolism of the pulmonary artery. However, the most effective measures to prevent these complications are very simple.

It is now proved that the vast majority of pneumonia in stroke occurs as a result of various disorders of swallowing and microaspiration. Therefore, testing and early detection of swallowing disorders is a priority. Do not ingest oral fluids in patients who have swallowed, - to facilitate swallowing, enter thickeners.

With any introduction of food or medications (regardless of the route of administration, either orally or through a probe), the patient should be in a semi-sitting position for 30 minutes after feeding. Sanitation of the oral cavity is carried out after each meal.

Catheterization of the bladder is carried out strictly according to the indications with observance of the rules of asepsis, since the majority of nosocomial infections of the urinary tract is associated with the use of permanent catheters. The urine is collected in a sterile urinal. If the passage of urine is broken through the catheter, it should not be washed, as this promotes the development of an ascending infection. In this case, a catheter replacement is necessary.

For the prevention of deep vein thrombosis of the lower leg, all patients are shown wearing compression stockings before the complete restoration of impaired motor functions. For the prevention of deep vein thrombosis of the lower leg and thromboembolism of the pulmonary artery, direct anticoagulants are also used. Preference should be given to low molecular weight heparins due to their better bioavailability, lower frequency of administration, predictable effects and the lack of the need for strict laboratory control in the vast majority of patients.

Specific treatment for ischemic stroke consists in reperfusion (thrombolytic, antiplatelet, anticoagulant) and neuroprotective therapy.

At present, fibrinolytic preparations of the first generation [for example, streptokinase, fibrinolysin (human)] are not used to treat ischemic stroke, since in all studies using these drugs a high frequency of hemorrhagic complications was shown, leading to significantly higher mortality rates in comparison with patients , who received a placebo.

For systemic thrombolytic therapy in ischemic stroke, alteplase is currently used, which is shown during the first 3 hours after the onset of stroke in patients aged 18 to 80 years.

Contraindications to systemic thrombolysis with the help of alteplase are the following:

• late onset of treatment (more than 3 hours after the onset of the first symptoms of stroke);
• signs of intracranial hemorrhage and the size of a hypodensitive focus more than a third of the basin of the middle cerebral artery at CT;
• a small neurological deficit or significant clinical improvement before the onset of thrombolysis, as well as a severe stroke;
• systolic blood pressure more than 185 mm Hg. And / or diastolic above 105 mm Hg.

In systemic thrombolysis, alteplase is administered at a dose of 0.9 mg / kg (maximum dose is 90 mg), 10% of the entire dose is administered as a bolus intravenously in a stream for 1 minute, the remaining dose is intravenously drip for 1 hour.

Intraarterial thrombolytic therapy, conducted under the control of X-ray angiography, can reduce the dose of thrombolytic and thereby reduce the number of hemorrhagic complications. Another indisputable advantage of intra-arterial thrombolysis is the possibility of its application within the 6-hour "therapeutic window".

One of the most promising areas of recanalization is surgical removal of thrombus (endovascular extraction or excision).

If thrombolysis after neuroimaging is not possible, patients with ischemic stroke are prescribed acetylsalicylic acid at a daily dose of 100-300 mg as early as possible. The early administration of the drug reduces the incidence of repeated strokes by 30% and the 14-day lethality by 11%.

The positive effect of direct anticoagulants in patients with stroke is currently not proven. In connection with this, heparin preparations are not used as a standard treatment for patients with all pathogenetic types of stroke. However, there are situations in which the appointment of heparin drugs is considered justified: the progression of atherothrombotic stroke or recurrent transient ischemic attacks, cardioembolic stroke, symptomatic dissection of extracranial arteries, thrombosis of venous sinuses, deficiency of proteins C and S.

When using heparins, it is necessary to cancel the antiplatelet agents, control activated partial thromboplastin time (strictly necessary for intravenous administration of heparin) and more stringent control of hemodynamics. In view of the antithrombin III-dependent effects of unfractionated heparin, when it is prescribed, it is necessary to determine the activity of antithrombin III and introduce fresh-frozen plasma or other antithrombin III donators, if necessary.

The use of iso- or hypervolemic hemodilution has also not been confirmed in randomized trials. It should be borne in mind that the hematocrit should be within the normal accepted values, since the excess of the latter breaks the blood rheology and promotes thrombogenesis.

Neuroprotection can be one of the most priority areas of therapy, since early use is possible already at the prehospital stage, before the nature of cerebral circulation disorders is clarified. The use of neuroprotectors can increase the share of transient ischemic attacks and "small" strokes among acute cerebrovascular disorders by ischemic type, significantly reduce the size of the cerebral infarction, lengthen the period of the "therapeutic window" (expanding the possibilities for thrombolytic therapy), and provide protection against reperfusion injury.

One of the means of primary neuroprotection, which blocks NMDA-dependent channels in a potential-dependent way, is magnesium ions. According to the international study, the use of magnesium sulfate at a dose of 65 mmol / day can significantly increase the proportion of patients with good neurologic recovery and reduce the incidence of adverse outcomes in ischemic stroke. A natural inhibitory neurotransmitter is the amino acid glycine, which has metabolic activity, the ability to bind aldehydes and ketones, and reduce the severity of the effects of oxidative stress. A randomized, double-blind, placebo-controlled study showed that sublingual application of 1.0-2.0 grams of glycine per day in the first days of stroke provides anti-ischemic protection of the brain in patients with different localization and severity of vascular lesions, positively affects the clinical outcome of the disease, more complete regression of focal neurological deficit, provides a statistically significant decrease in the indicator of 30-day mortality.

An important area of neuroprotective therapy is the use of drugs with neurotrophic and neuromodulatory properties. Low-molecular neuropeptides freely penetrate the blood-brain barrier and have a multifaceted effect on the central nervous system, which is accompanied by high efficiency and a pronounced directionality of action, provided they have a very low concentration in the body. The results of a randomized double-blind, placebo-controlled study of semax (synthetic analogue of adrenocorticotropic hormone) showed that the drug (at a dose of 12-18 μg / kg per day for 5 days) had positive effects on the course of the disease, leading to a significant decrease in 30-day mortality, improvement of clinical outcome and functional recovery of patients.

One of the most well-known drugs of the neurotrophic series is cerebrolysin - protein hydrolyzate extracts from the brain of pigs. In a randomized, double-blind, placebo-controlled study of cerebrolysin in ischemic stroke, in which 148 patients were included, it was found that with the use of high (50 ml) doses of the drug, significantly more complete regression of motor disorders to the 21st day and 3 months from the beginning diseases, as well as improvement of cognitive functions, which contributes to reliably more complete degree of functional recovery.

In a similar placebo-controlled study, the authentic efficacy of the domestic polypeptide preparation of cortexin-hydrolyzate extracts from the cerebral cortex of young calves and pigs was demonstrated. Cortexin is administered intramuscularly at 10 mg twice a day for 10 days. The maximum effect is observed on the 11th day of treatment: cognitive and motor disorders clearly regress, especially those associated with ischemia of cortical structures of the brain.

As an antihypoxant antioxidant, which has a pronounced neuroprotective effect, ethylmethyl hydroxypyridine succinate (mexidol) can be used. As a result of a randomized, double-blind, placebo-controlled study, early recovery of impaired functions and a better functional recovery of patients with a 300 mg dose were detected starting from the first 6-12 hours from the onset of development of the former. Symptoms of stroke compared with placebo.

Nootropics (derivatives of GABA) and choline derivatives (choline alfoscerate) enhance regenerative and reparative processes, contributing to the restoration of impaired functions.

It is known that the brain and spinal cord do not possess a depositing property and the cessation of blood flow, that is, the delivery of energy materials, leads to the death of neurons within 5-8 min. Therefore, the introduction of neuroprotective drugs is required from the first minutes of the brain stroke of any pathogenesis. It is expedient not a one-stage, but a sequential introduction of drugs with different mechanisms of neuroprotective action.

Thus, the introduction of modern complex approaches to the therapy of ischemic stroke (a combination of reperfusion and neuroprotection, as well as early rehabilitation against the background of well-adjusted basic therapy) makes it possible to achieve significant success in the treatment of such patients.

Surgical treatment of ischemic stroke

The goal of surgical decompression with extensive cerebral infarctions is to reduce intracranial pressure, increase perfusion pressure and maintain cerebral blood flow. In a series of prospective observations, surgical decompression treatment with extensive malignant hemispheric infarction allowed to reduce the lethality from 80 to 30% without increasing the number of severely invalidated survivors. With cerebellar infarction with the development of hydrocephalus, ventriculostomy and decompression become the operations of choice. As with a vast supratentorial infarction, the operation should be performed before the development of symptoms of brainstem wedging.

Approximate terms of incapacity for work

The duration of inpatient treatment of a patient with transient ischemic attack is up to 7 days, with ischemic stroke without disruption of vital functions - 21 days, with violations of vital functions - 30 days. The duration of the temporary disability sheet is up to 30 days after the onset of the disease.

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

Further management

For patients who have suffered transient impairment of cerebral circulation or stroke, an individual plan for secondary prevention should be developed taking into account available risk factors, as well as a program of rehabilitation measures. After discharge from the hospital for the patient should observe a neurologist, a therapist, if necessary - a vascular surgeon, a neurosurgeon.

Forecast

The prognosis depends on many factors, first of all on the volume and localization of the lesion of the brain, the severity of the concomitant pathology, the age of the patient. Mortality in ischemic stroke is 15-20%. The greatest severity of the condition is noted in the first 3-5 days, which is due to the increase in cerebral edema in the area of the lesion. Then follows a period of stabilization or improvement with a gradual restoration of impaired functions.

[7], [8], [9]