Treatment of ischemic stroke

The main objectives of the treatment of ischemic stroke (medicinal, surgical, rehabilitation) are the restoration of impaired neurological functions, the prevention of complications and the fight against them, secondary prevention of repeated cerebrovascular accidents.

Indications for hospitalization

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

Relative restrictions for hospitalization:

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

Indications for consultation with other specialists

A multidisciplinary approach to managing a patient with stroke is necessary, with the coordination of efforts not only of neurologists, but also of specialists of other profiles. All patients with stroke should be examined by a therapist (cardiologist), in an emergency - if acute cardiac pathology is suspected. A consultation with an ophthalmologist (examination of the fundus) is also necessary. If stenosis of the main arteries of the head is detected by more than 60%, a consultation with a vascular surgeon is indicated to decide on performing carotid endarterectomy or stenting of the carotid arteries. In case of extensive hemispheric cerebral infarction or cerebellar infarction, a consultation with a neurosurgeon is necessary to decide on decompression surgery.

Non-drug treatment

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

Drug treatment

Treatment of ischemic stroke is most effective in a specialized vascular department with a coordinated multidisciplinary approach to patient care. A hospital with a specialized department for treating patients with stroke must have an intensive care unit with the ability to perform 24-hour CT, ECG, chest X-ray, clinical and biochemical blood tests, and ultrasound vascular studies.

The most effective treatment is to start in the first 3-6 hours after the first signs of stroke appear (the “therapeutic window” period).

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

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

When the neurological status stabilizes, it is possible to gradually and carefully reduce blood pressure to values that exceed the patient’s normal values by 15-20%.

If it is necessary 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 the blood plasma. In the presence of cerebral edema, it is possible to maintain a negative water balance, but only if this does not lead to a decrease in blood pressure.

The main infusion solution for treating patients with stroke is 0.9% sodium chloride solution. Hypo-osmolar solutions (0.45% sodium chloride solution, 5% glucose solution) are contraindicated due to the risk of increasing cerebral edema. Routine use of glucose-containing solutions is also inappropriate due to the risk of developing hyperglycemia.

The development of both hypoglycemic and hyperglycemic conditions in patients with stroke is extremely unfavorable. An absolute indication for the administration of short-acting insulin is considered to be a blood glucose level of 10 mmol/l or more. However, a blood glucose level of 6.1 mmol/l is already considered an unfavorable prognostic factor, regardless of the presence or absence of diabetes mellitus in the anamnesis.

Patients with diabetes mellitus should be transferred to subcutaneous injections of short-acting insulin. Provided that glycemic control is adequate, an exception may be patients who are conscious, without aphasic disorders and swallowing disorders, who are able to continue taking hypoglycemic drugs and/or insulin according to their usual regimens.

During the first 48 hours, all patients with stroke require continuous or periodic transcutaneous determination of arterial blood hemoglobin oxygen saturation. Indications for further measurement of this and other oxygen status indicators are determined individually and depend on the presence of general cerebral symptoms, airway patency, impaired gas exchange in the lungs, and the state of the blood's gas transport function.

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

All patients with decreased consciousness (8 points or less on the Glasgow Coma Scale) require tracheal intubation. In addition, intubation is indicated for aspiration or high risk of aspiration with uncontrollable vomiting and pronounced bulbar or pseudobulbar syndrome. The decision on the need for mechanical ventilation is made based on the basic general resuscitation principles. The prognosis for stroke patients undergoing intubation is not always unfavorable.

Reducing body temperature is indicated when hyperthermia develops above 37.5 °C. It is especially necessary to strictly control and correct body temperature in patients with impaired consciousness, since hyperthermia increases the size of the infarction and negatively affects the clinical outcome. It is possible to use NSAIDs (for example, paracetamol), as well as physical methods of reducing temperature (ice on the main vessels and liver area, wrapping with a cold sheet, rubbing with alcohol, using special devices, etc.).

Despite the significant impact of hyperthermia on the course and outcome of stroke, prophylactic administration of antibacterial, antifungal and antiviral drugs is unacceptable. Unreasonable use of antibiotics leads to suppression of the growth of microorganisms sensitive to them and, consequently, to the proliferation of resistant ones. The occurrence of infectious damage to the organ under these conditions leads to the natural ineffectiveness of the prophylactically administered antibacterial drugs and dictates the choice of other, usually more expensive antibiotics.

All patients with decreased alertness, clinical (Mondonesi's symptom, Bechterew's zygomatic symptom) or neuroimaging signs of cerebral edema and/or increased intracranial pressure should be kept in bed with the head end elevated to 30° (without flexing the neck!). In this category of patients, epileptic seizures, cough, motor agitation and pain should be excluded or minimized. The introduction of hypoosmolar solutions is contraindicated!

If signs of impaired consciousness appear and/or increase due to the development of primary or secondary damage to the brainstem, osmotic drugs should be administered (for other causes of impaired consciousness, acute somatic diseases and syndromes should be found and eliminated first). Mannitol is administered at a dose of 0.5-1.0 g/kg every 3-6 hours or 10% glycerol at 250 ml every 6 hours intravenously quickly. When prescribing these drugs, it is necessary to monitor the osmolality of the blood plasma. The administration of osmotic diuretics with an osmolality exceeding 320 mosmol/kg gives an unpredictable effect.

As an anti-edematous agent, it is possible to use a 3% solution of sodium chloride, 100 ml 5 times a day. To increase oncotic pressure, an albumin solution can be used (preference should be given to a 20% solution).

The administration of decongestants should not be prophylactic or planned. The prescription of these drugs always implies a deterioration in the patient's condition and requires close clinical, monitoring and laboratory observation.

Early and adequate nutrition of patients, as well as replenishment of water and electrolyte losses. - a mandatory and daily task of basic therapy regardless of the location of the patient (resuscitation, intensive care unit or neurological department). The development of certain swallowing disorders, as well as impaired consciousness are indications for immediate enteral tube feeding. The calculation of the necessary doses of nutrients is carried out taking into account the physiological losses and metabolic needs of the body, especially since the development of ischemia causes hypercatabolism-hypermetabolism syndrome. Insufficiency of enterally administered balanced mixtures requires additional parenteral nutrition.

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

The most common complications of stroke are pneumonia, urinary tract infections, deep vein thrombosis of the leg, and pulmonary embolism. However, the most effective measures to prevent these complications are very simple.

It has now been proven that the vast majority of stroke pneumonias occur as a result of some swallowing disorders and microaspirations. Therefore, testing and early detection of swallowing disorders is a priority. Oral fluid intake by patients with swallowing disorders is unacceptable - thickeners must be administered to facilitate swallowing.

When any food or medication is administered (regardless of the method of administration - orally or through a tube), the patient must be in a semi-sitting position for 30 minutes after feeding. Oral cavity sanitation is performed after each meal.

Catheterization of the urinary bladder is performed strictly according to indications, observing the rules of asepsis, since most hospital-acquired urinary tract infections are associated with the use of permanent catheters. Urine is collected in a sterile urine collector. If the passage of urine through the catheter is disrupted, flushing it is unacceptable, since this contributes to the development of ascending infection. In this case, the catheter must be replaced.

To prevent deep vein thrombosis of the lower leg, all patients are recommended to wear compression stockings until the impaired motor functions are completely restored. Direct anticoagulants are also used to prevent deep vein thrombosis of the lower leg and pulmonary embolism. Preference should be given to low-molecular heparins due to their better bioavailability, lower frequency of administration, predictability of effects, and the absence of the need for strict laboratory monitoring in the vast majority of patients.

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

Currently, first-generation fibrinolytic drugs [eg, streptokinase, fibrinolysin (human)] are not used for the treatment of ischemic stroke, since all studies using these drugs have shown a high incidence of hemorrhagic complications, leading to significantly higher mortality rates compared with patients receiving placebo.

Alteplase is currently used for systemic thrombolytic therapy for ischemic stroke, which is indicated within the first 3 hours after the onset of stroke in patients aged 18 to 80 years.

Contraindications to systemic thrombolysis with alteplase are as follows:

• late start of treatment (more than 3 hours after the first symptoms of stroke);
• signs of intracranial hemorrhage and the size of the hypodense lesion more than a third of the middle cerebral artery basin on CT;
• minor neurological deficit or significant clinical improvement before the start of thrombolysis, as well as severe stroke;
• systolic blood pressure greater than 185 mmHg and/or diastolic greater than 105 mmHg.

For systemic thrombolysis, alteplase is administered at a dose of 0.9 mg/kg (maximum dose - 90 mg), 10% of the total dose is administered as a bolus intravenously by jet stream over 1 minute, the remaining dose is administered intravenously by drip over 1 hour.

Intra-arterial thrombolytic therapy, performed under the control of X-ray angiography, allows to reduce the dose of thrombolytics and thereby reduce the number of hemorrhagic complications. Another indisputable advantage of intra-arterial thrombolysis is the possibility of its use within a 6-hour "therapeutic window".

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

If thrombolysis cannot be performed after neuroimaging, patients with ischemic stroke are prescribed acetylsalicylic acid at a daily dose of 100-300 mg as early as possible. Early administration of the drug reduces the incidence of recurrent strokes by 30% and 14-day mortality by 11%.

The positive effect of direct anticoagulants in patients with stroke has not been proven at present. In this regard, heparin preparations are not used as a standard treatment for patients with all pathogenetic types of stroke. However, situations have been identified in which the prescription of heparin preparations is considered justified: progressive course 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 discontinue antiplatelet agents, monitor activated partial thromboplastin time (strictly mandatory with intravenous heparin administration), and more stringent hemodynamic monitoring. Due to the antithrombin III-dependent effects of unfractionated heparin, when it is prescribed, antithrombin III activity should be determined and fresh frozen plasma or other antithrombin III donors should be administered if necessary.

The use of iso- or hypervolemic hemodilution has also not been confirmed in randomized studies. It should be taken into account that the hematocrit value should be within the generally accepted normal values, since exceeding the latter disrupts blood rheology and promotes thrombus formation.

Neuroprotection may become one of the most priority areas of therapy, since their early use is possible already at the prehospital stage, before the nature of cerebrovascular accidents is determined. The use of neuroprotectors may increase the proportion of transient ischemic attacks and "minor" strokes among acute cerebrovascular accidents of the ischemic type, significantly reduce the size of cerebral infarction, extend the period of the "therapeutic window" (expanding the possibilities for thrombolytic therapy), and provide protection against reperfusion injury.

One of the primary neuroprotective agents that block NMDA-dependent channels in a potential-dependent manner are magnesium ions. According to the data of an international study, the use of magnesium sulfate at a dose of 65 mmol/day allows to reliably increase the proportion of patients with good neurological recovery and reduce the frequency of adverse outcomes in ischemic stroke. 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, serves as a natural inhibitory neurotransmitter. A randomized, double-blind, placebo-controlled study showed that sublingual use of 1.0-2.0 g 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 damage, has a positive effect on the clinical outcome of the disease, contributes to a reliably more complete regression of focal neurological deficit, and provides a statistically significant decrease in the 30-day mortality rate.

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 pronounced direction of action, provided their concentration in the body is very low. The results of a randomized, double-blind, placebo-controlled study of Semax (a synthetic analogue of adrenocorticotropic hormone) showed that the drug (at a dose of 12-18 mcg/kg per day for 5 days) has positive effects on the course of the disease, leads to a reliable decrease in 30-day mortality rates, improved clinical outcome and functional recovery of patients.

One of the most well-known neurotrophic drugs is Cerebrolysin, a protein hydrolysate of pig brain extract. A randomized, double-blind, placebo-controlled study of Cerebrolysin in ischemic stroke, which included 148 patients, found that when using high (50 ml) doses of the drug, a significantly more complete regression of motor disorders was noted by the 21st day and 3 months after the onset of the disease, as well as an improvement in cognitive functions, which contributes to a significantly more complete degree of functional recovery.

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

Ethylmethylhydroxypyridine succinate (mexidol) can be used as an antihypoxant-antioxidant with a pronounced neuroprotective effect. A randomized, double-blind, placebo-controlled study revealed faster recovery of impaired functions and better functional recovery of patients when the drug was prescribed at a dose of 300 mg starting from the first 6-12 hours from the onset of the first symptoms of stroke compared to placebo.

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

It is known that the brain and spinal cord do not have a depositing property and the cessation of blood flow, i.e. the delivery of energy materials, within 5-8 minutes leads to the death of neurons. Therefore, it is necessary to administer neuroprotective drugs from the first minutes-hours of a cerebral stroke of any pathogenesis. It is advisable not to administer drugs at once, but sequentially with different mechanisms of neuroprotective action.

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

Surgical treatment of ischemic stroke

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

Approximate periods of incapacity for work

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

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Further management

For patients who have suffered a transient ischemic attack or stroke, an individual secondary prevention plan should be developed taking into account the existing risk factors, as well as a rehabilitation program. After discharge from the hospital, the patient should be monitored by a neurologist, therapist, and, if necessary, a vascular surgeon or neurosurgeon.

Forecast

The prognosis depends on many factors, primarily on the volume and localization of the brain lesion, the severity of the associated pathology, and the patient's age. 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.

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