Dyscirculatory encephalopathy: symptoms

Symptoms of dyscirculatory encephalopathy

The main symptoms of discirculatory encephalopathy: emotional disorders, polymorphic motor disorders, memory impairment and learning ability, gradually leading to maladaptation of patients. Clinical features of chronic cerebral ischemia - progressive course, staging, syndromic.

In domestic neurology for a long time to chronic insufficiency of cerebral circulation, along with discirculatory encephalopathy, the initial manifestations of cerebral circulatory insufficiency were also included. At present, it is considered unfounded to isolate such a syndrome as "initial manifestations of cerebral blood supply deficiency," given the non-specific nature of the asthenic complaints presented and the frequent overdiagnosis of the vascular genesis of these manifestations. The presence of headache, dizziness (non-systemic nature), memory loss, sleep disturbance, head noise, ringing in the ears, blurred vision, general weakness, increased fatigue, decreased efficiency and emotional lability, in addition to chronic cerebral circulatory failure, may indicate other diseases and conditions . In addition, these subjective sensations sometimes simply inform the body of fatigue. With the confirmation of the vascular genesis of the asthenic syndrome with the help of additional research methods and the detection of focal neurologic symptoms, the diagnosis of "discirculatory encephalopathy" is established.

It should be noted the inverse relationship between the presence of complaints, especially reflecting the ability to cognitive activity (memory, attention), and the degree of severity of chronic insufficiency of cerebral circulation: the more cognitive (cognitive) functions suffer, the less complaints. Thus, subjective manifestations in the form of complaints can not reflect either the severity or the nature of the process.

The core of the clinical picture of dyscirculatory encephalopathy has recently been recognized as cognitive impairments, which are already detected in the first stage and progressively increasing to the third stage. In parallel, emotional disorders develop (emotional lability, inertia, lack of emotional reaction, loss of interest), various motor disorders (from programming and control to execution as complex neo-kinetic, higher automated, and simple reflex movements).

Stages of discirculatory encephalopathy

Dyscirculatory encephalopathy is usually divided into 3 stages.

• At stage I, the above complaints are combined with diffuse microfocal neurologic symptoms in the form of anisoreflexia, inadequacy of convergence, and abrupt reflexes of oral automatism. There may be slight changes in gait (shortening of the step length, slowness of walking), decrease in stability and uncertainty when performing coordination tests. Often, emotional and personality disorders (irritability, emotional lability, anxious and depressive traits) are noted. Even at this stage, slight cognitive impairments of the neurodynamic type arise: slowing and inertia of intellectual activity, exhaustion, fluctuation of attention, a decrease in the volume of operative memory. Patients cope with neuropsychological tests and work, in which no account is taken of the execution time. The life of patients is not limited.
• II stage is characterized by an increase in neurological symptoms with the possible formation of a non-structured, but dominant syndrome. Identify individual extrapyramidal disorders, incomplete pseudobulbar syndrome, ataxia, central nervous system dysfunction (prozo and glossoparesis). Complaints become less pronounced and less significant for the patient. Emotional disorders are aggravated. Cognitive dysfunction grows to a moderate degree, neurodynamic disorders are supplemented with dysregulatory (frontal-subcortical syndrome). The ability to plan and control one's actions deteriorates. The execution of tasks that are not limited by the time frame is violated, but the ability to compensate (the recognition and the possibility of using hints are retained). At this stage, there may be signs of a decline in professional and social adaptation.
• Stage III is manifested by the presence of several neurologic syndromes. Developed gross violations of walking and balance with frequent falls, expressed cerebellar disorders, Parkinsonian syndrome, urinary incontinence. The criticism to the condition decreases, owing to what the quantity of complaints decreases. There may be pronounced personality and behavioral disorders in the form of disinhibition, explosivity, psychotic disorders, apatiko-abulic syndrome. Neurodynamic and dysregulatory cognitive syndromes are joined by operational disturbances (defects of memory, speech, praxis, thinking, visual-spatial function). Cognitive disorders often reach the level of dementia, when disadaptation manifests itself not only in social and professional activities, but also in everyday life. The sick are incapacitated, in some cases gradually lose the ability to serve themselves.

Neurological syndromes with discirculatory encephalopathy

Most often, with chronic cerebral circulatory failure, vestibulosis, pyramidal, amyostatic, pseudobulbar, psycho-organic syndromes, as well as their combinations are revealed. Sometimes they separate the cephalgic syndrome. At the heart of all the syndromes characteristic of dyscirculatory encephalopathy is the dissociation of the bonds due to diffuse anoxic-ischemic damage to the white matter.

With vestibulozmozhechkovom (or vestibuloatakticheskom) syndrome, subjective complaints of dizziness and instability when walking are combined with nystagmus and coordination disorders. Disorders can be caused by cerebellar-stem cell dysfunction due to circulatory insufficiency in the vertebrobasilar system and by dissociation of the frontal-stem lines in the diffuse lesion of the white matter of the cerebral hemispheres due to cerebral blood flow disturbance in the internal carotid artery system. Ischemic neuropathy of the pre-collateral nerve is also possible. Thus, ataxia in this syndrome can be of 3 types: cerebellar, vestibular. Frontal. The latter is also called apraxia walk, when the patient loses locomotion skills in the absence of paresis, coordinator, vestibular disorders, and sensitive disorders.

Pyramidal syndrome with discirculatory encephalopathy is characterized by high tendon and positive pathological reflexes, often asymmetric. Pareses are not clearly expressed or absent. Their presence indicates a previous stroke.

Parkinsonian syndrome in the framework of discirculatory encephalopathy is represented by delayed movements, hypomia, unstable muscular rigidity, more often in the legs, with the phenomenon of "counteraction", when the resistance of muscles involuntarily increases with passive movements. Tremor, as a rule, is absent. Gait disturbances are characterized by slowing down walking speed, decreasing step size (microbasia), "sliding". Shuffling step, small and rapid trampling in place (before walking and turning). Difficulties during turns during walking are manifested not only by stamping on the spot, but also by turning the whole body with imbalance of the balance, which may be accompanied by a fall. Falls in these patients occur in the phenomena of propulsions, retropulsions, lateropulses and also can precede walking due to a violation of the initiation of locomotion (a symptom of "adhering legs"). If there is an obstacle in front of the patient (narrow door, narrow passage), the center of gravity is shifted forward, in the direction of movement, and the feet are trampled in place, which can cause a fall.

The occurrence of vascular Parkinsonian syndrome in chronic cerebral circulatory insufficiency is due to the defeat of noncortical ganglia, and cortical-striatal and cortical-stem connections, so treatment with drugs containing levodopa does not significantly improve this contingent of patients.

It should be emphasized that in cases of chronic insufficiency of cerebral circulation, motor disorders are manifested primarily by disorders of walking and balance. The genesis of these disorders is associated with the damage of pyramidal, extrapyramidal and cerebellar systems. Not the last place is assigned to the disruption of the functioning of complex systems of motor control, which is provided by the frontal cortex and its connections with subcortical and stem structures. With the defeat of motor control, the syndromes of dysbasia and astasia (subcortical, frontal, frontal-subcortical) develop, otherwise they can be called apraxia of walking and retention of the vertical posture. These syndromes are accompanied by frequent episodes of a sudden fall.

Pseudobulbar syndrome, the morphological basis of which is bilateral damage to the cortical-nuclear pathways, occurs with chronic cerebral circulatory insufficiency quite often. Its manifestations with discirculatory encephalopathy do not differ from those in other etiology: dysarthria, dysphagia, dysphonia, episodes of violent crying or laughter and reflexes of oral automatism arise and gradually increase. The pharyngeal and palatine reflexes are preserved and even high; language without atrophic changes and fibrillar twitching, which makes it possible to differentiate the pseudobulbar syndrome from bulbar, caused by the defeat of the medulla oblongata and / or the cranial nerves emerging from it and clinically manifested by the same triad of symptoms (dysarthria, dysphagia, dysphonia).

The psycho-organic (psychopathological) syndrome can be manifested by emotional-affective disorders (asthenodepressive, anxious-depressive), cognitive (cognitive) disorders - from mild mental and intellectual disorders to various degrees of dementia.

The severity of the cephalgic syndrome decreases with the progression of the disease. Among the mechanisms of cephalalgia formation in patients with chronic cerebral circulatory insufficiency, one can consider myofascial syndrome in the background of osteochondrosis of the cervical spine, as well as tension headache (HDN) - a variant of psychhalgia, often occurring against a background of depression.