Small stroke (micro-stroke). Precursors of a brain catastrophe

What is a stroke

The essence of a stroke is the cessation of blood supply and functioning of a part of the brain as a result of damage to a vessel.
The larger the affected area, the more severe the stroke. Necrosis of a portion of the brain substance is called an infarction [3]. There is a high risk of death in the first few hours, and then in the period up to 28 days after a vascular accident. The annual mortality rate from stroke in the Russian Federation is 374 cases per 100,000 [10]. In 2018, 35% of patients died in the acute period of stroke; by the end of the first year, this figure increases by 15%, and in general, in the first 5 years, the mortality rate of strokes is 44% [11]. The mortality rate from stroke was 92.9 per 100,000 population, and the hospital mortality rate was 19.1% [5].

Long-term disability is most likely for patients who have suffered a stroke. The prevalence of primary disability due to stroke in 2018 was 3.2 per 10 thousand population [2]. Of these, 31% need constant care, 20% have severe mobility limitations, and only 8% return to work [3]. The prevalence of recurrent strokes in 2014 was 0.79%, of which ischemic

strokes account for 87.5% [9].

Causes of stroke

Depending on the cause of cerebrovascular accident, ischemic and hemorrhagic strokes are distinguished.

Ischemic stroke occurs as a result of blockage of cerebral vessels by a blood clot, when gradually less and less blood flows to an area of ​​the brain. Hemorrhagic stroke develops as a result of rupture of a vessel and hemorrhage in the brain tissue, as a result of which the blood supply to its area abruptly stops. Hemorrhage can be into the subarachnoid space (SAS) or directly into the cerebral substance (ICH). The ratio of ischemic and hemorrhagic strokes is 4-5:1 [4].

Pathologically, a stroke can be cardioembolic, lacunar, atherothrombotic, or another, including unknown, etiology (TOAST classification) [10].

Predisposing factors:

• men from 45 to 59 years old;
• age 70 years and older (for both sexes) [4];
• arterial hypertension;
• atrial fibrillation;
• atherosclerosis of cerebral vessels;
• coagulopathy, thrombophilia, anemia;
• arteriovenous malformations;
• osteochondrosis with damage to the vertebral artery;
• brain tumors;
• dyslipoproteinemia;
• obesity;
• diabetes;
• intermittent claudication;
• mechanical prostheses of heart valves and blood vessels;
• IHD, myocardial infarction less than 6 months before the stroke;
• other cardiac diseases;
• smoking, alcoholism;
• family history of stroke;
• sedentary lifestyle;
• stress [1, 3].

Features of stroke in women

If in men the most likely risk of stroke is after 40 years, then in women this probability reduces the age limit to 18 years. The main reason for this fact is that physiologically women are more prone to aneurysm (a feature of the structure of the vessel with congenital expansion). Constant stress, high blood pressure, and emotional experiences lead to ruptures in the walls of blood vessels, and hemorrhage occurs in the cranial cavity.

During pregnancy and childbirth, as well as hormonal changes, there is a lot of stress on the body. This in turn greatly affects the blood circulation process in the brain. Some symptoms of eclampsia and preeclampsia are mistaken for ischemic ones. Such atypical symptoms of a stroke can significantly delay the provision of first aid to the victim and create a life-threatening situation for further treatment of the consequences of a stroke.

Contraceptive drugs increase the risk of vascular thrombosis significantly. Since the use of such drugs for a long time affects blood clotting.

Signs of an incipient stroke

The onset of a hemorrhagic stroke is characterized by the following symptoms:

• severe headache;
• increased blood pressure;
• vomit;
• dizziness;
• loss of consciousness;
• weakness in the limbs;
• visual impairment;
• seizures [1].

The onset of ischemic stroke is gradual; within an hour, some of the following symptoms appear:

• facial asymmetry, numbness;
• difficulty speaking – incoherent, impaired understanding;
• double vision, visual disturbances;
• headache;
• numbness, limited mobility in the limbs, often on one side;
• dizziness, imbalance, staggering, staggering gait;
• confusion with disorientation, subsequently there may be loss of consciousness [3].

If one or more of these signs appear, you should:

1. Sit the patient down, providing access to fresh air.
2. Call emergency medical help immediately.
3. If the patient is conscious and able to chew and swallow, give him one aspirin tablet.

The patient must be hospitalized in a neurological or neurosurgical department, where stroke treatment will be carried out. The sooner the patient is in the hospital, the more effective the therapy.

What are the causes, symptoms, consequences of this phenomenon?

The causes of TIA are atherosclerotic damage to the arteries, arterial hypertension, heart disease, diabetes mellitus, etc. The above reasons account for approximately 95% of TIAs and are dominant in elderly and senile people. In approximately 5% of cases, more often in young people.

TIAs are caused by other reasons:

• arterial dissection;
• vasculitis, congenital anomalies of the arteries;
• migraine;
• hematological disorders;
• infections;
• malignant neoplasms;
• oral contraceptives;
• pregnancy and postpartum period;
• pathological tortuosity of blood vessels;
• extravasal compression of the vertebral arteries by pathologically altered cervical vertebrae.

It should be noted that TIA is characterized by a sudden onset and rapid regression of symptoms, most often within 1 hour.

You need to pay attention to the following symptoms:

• Weakness in one upper and/or lower limb. Facial paralysis may occur.
• Numbness of half the face and/or limbs.
• Transient visual impairment in one eye.
• Speech disorders: difficulties in remembering words, pronouncing or perceiving words.
• Coordination problems: Loss of balance when moving your arms, legs, or body. The patient may stagger or fall when walking or standing.
• Diplopia: double or blurred image.
• Dizziness: The patient describes it not as a strange sensation in the head, but as if he himself is dizzy.
• Difficulty swallowing.
• Behavioral disturbances: the patient does not perceive what is said or makes uncoordinated movements. Possibly excessive sleep cravings. Possible agitation or psychosis.

TIA can be a precursor to all types of stroke, but most often precedes the development of atherothrombotic stroke. Against the background of TIA, 25-50% of atherothrombotic strokes, 11-30% of cardioembolic, 11-14% of lacunar and 9-11% of hemorrhagic strokes develop.

Symptoms of a stroke

Stroke leads to various brain injuries, depending on the location of the lesion and the pathological type of cerebrovascular accident:

• disturbances of movement in the limbs: from restrictions (paresis) to complete paralysis. When the lesion is localized on the right, the left limbs suffer; with a left-sided lesion, right hemiparesis is formed; in some cases, movements in all limbs may stop (tetraparesis or double hemiparesis);
• sensory disturbances on one or both sides;
• speech disorders (dysarthria - poor articulation; aphasia - inability to pronounce and understand words, write and read);
• ataxia (impaired coordination of movements, “overshooting”, unsteadiness, imbalance, tremor);
• visual impairment: from blindness to double vision and gaze paresis;
• hearing impairment and dizziness;
• violation of mental functions (consciousness, thinking, attention, memory, will, behavior);
• paresis of the soft palate and pharynx, swallowing disorders;
• disorders of urination and defecation;
• depression of respiration and vascular tone;
• increased intracranial pressure;
• patients complain of headaches, vomiting, hiccups, yawning, shoulder pain;
• consciousness is gradually depressed to the point of coma [1, 3].

Causes of death may include cerebral edema, pneumonia, heart failure, and recurrent stroke. In severe cases, “locked-in syndrome” may develop: the patient is conscious, but cannot move, swallow or speak [3].

Signs and symptoms after a stroke

The symptoms of a stroke largely depend on the cause of the disease. The first signs of a stroke are the following symptoms:

• sudden numbness or weakness in an arm or leg on one side of the body;
• confusion;
• Strong headache;
• speech disorder;
• decreased visual acuity;
• dizziness;
• loss of balance or coordination.

The speed at which symptoms of an ischemic stroke appear may indicate its origin: if an acute cerebrovascular accident is caused by an embolism, the disease is sudden. Headache and seizures may develop within seconds of arterial thromboembolism.

In patients with the consequences of a stroke, there are three main types of disorders:

• damage, defect. The following damages after a stroke are distinguished: motor, cognitive, emotional-volitional, speech, visual, sensory, sexual and pelvic disorders;
• impaired ability. Expressed in impairment of walking and self-care;
• impairment of social functioning. It is expressed in the restriction of the implementation of the social role that was the norm for the patient before the illness.

Symptoms after a stroke go away if doctors begin rehabilitation measures in a timely manner. When a patient is admitted to the neurology clinic of the Yusupov Hospital, a team consisting of the following specialists is included in the rehabilitation process:

• neurologists;
• therapists;
• kinesitherapy specialists;
• aphasiologists;
• massage therapists;
• physiotherapists;
• acupuncturists;
• psychologists;
• biofeedback specialists.

Muscle pain due to stroke

Muscle pain after a stroke, which should be treated immediately, occurs in most patients. Muscle soreness can interfere with the body's recovery. Post-stroke pain can be strategic or thalamic. Strategic pain occurs in the area of ​​the brain that controls sensations, particularly pain, and is caused by spasms. Thalamic pain appears after a stroke in one side of the body several months after the circulatory disorder.

The occurrence of pain after a stroke can be associated with various factors. Neurologists and rehabilitation specialists advise patients to follow recommendations that will prevent the onset of this condition. Measures to prevent muscle pain after a stroke:

• do not take hot baths;
• prefer clothes made from natural materials, do not wear light clothes;
• be in a comfortable position and avoid tightly grouping the body;
• do not put pressure on the affected side;
• use special devices for paralyzed and weakened limbs;
• fix the paralyzed arm while sitting so that the pain localized in the shoulder does not get worse;
• When moving, support from another person is desirable.

If you have pain in the legs after a stroke, it is important to trust treatment to qualified neurologists and rehabilitation specialists.

Consequences of a stroke

There are transient ischemic attack (less than a day), minor stroke (from 1 day to 3 weeks) and stroke with persistent residual effects. The consequences of a stroke are expressed mainly in motor and sensory disorders, the formation of muscle contractures (pronounced constant restriction of movements in the joints), speech and swallowing disorders. General symptoms may also remain, including confusion, disturbances in thinking, will, and emotional regulation. Complications can develop: from epilepsy to bedsores, encephalopathy and anxiety-depressive syndrome [1, 3].

The relationship between brain regions and the clinical picture of stroke

If the right lobe is affected, this is expressed by paralysis of the left limbs or loss of sensitivity in them.
The patient has a pronounced depressive state and a decrease in the desire for recovery. If the hippocampus area is affected, then the patient cannot grasp objects with his hand, loses the ability to navigate in space, cannot remember what happened yesterday, but memories of a longer period are preserved.

The hippocampus is responsible for emotions, short-term and long-term, spatial memory necessary for orientation in space.

If the left lobe is affected, then paralysis, decreased or loss of sensitivity in the right half of the body is characteristic, the patient does not perceive speech and speaks inarticulately.

If the cerebellum is affected, there is a lack of coordination, the patient feels nausea and dizziness. When the stem structures are damaged, the patient may experience double vision, the act of swallowing is disrupted, and involuntary movements occur.

Diagnosis of strokes

First of all, it is necessary to conduct a detailed neurological examination. Instrumental diagnostic studies and laboratory tests are also prescribed. In case of a stroke, in the first hours, an MRI or CT scan of the brain is performed, if necessary, CT or MR angiography, color Doppler mapping of blood flow, ECG or Holter monitoring, echocardiography as indicated, monitoring of blood pressure, saturation, assessment of the risk of developing bedsores, assessment of swallowing function [ 1, 3, 6].

Tests for stroke

• Complete clinical blood test, including erythrocyte sedimentation rate (ESR).
• Biochemical blood test with determination of C-reactive protein and homocysteine, glucose level, platelet count, activated partial thromboplastin time, INR.
• Interleukin 10.
• Extended coagulogram.
• Determination of acid-base status.
• General urine analysis.

To prepare for neurosurgical intervention, a blood test is additionally performed for hepatitis, syphilis, HIV, blood group and Rh factor determination.

Stroke treatment

Treatment of stroke is regulated by relevant clinical guidelines and the Procedure for providing medical care to patients with acute cerebrovascular accident. In the first hours, thrombolytic therapy is carried out and subsequently - prevention of thrombus formation. For hemorrhagic stroke, neurosurgery may be performed. They normalize blood pressure, water-electrolyte balance, glucose levels in peripheral blood and urine, support the basic vital functions of the body and prevent complications. Drug therapy is also aimed at improving the affected functions of the nervous system [1, 3, 6].

Who is at risk

There are people who need to be especially wary of developing a stroke, as they are at risk.

Among them:

• Persons with hypertension.
• Patients with diabetes.
• Men and women over 65 years of age.
• People with abdominal obesity.
• Persons with a hereditary predisposition to vascular pathologies.
• Patients who have previously had a stroke or heart attack.
• Patients with diagnosed atherosclerosis.
• Women over 35 years of age taking oral contraceptives.
• Smokers.
• People suffering from heart rhythm disturbances.
• People with high cholesterol levels.

Most often, patients with the listed diagnoses are registered at the dispensary. Special mention should be made of people living in a state of chronic stress. Emotional stress negatively affects all systems of the body and can cause a stroke.

Stroke rehabilitation

Stroke is a disease in which rehabilitation and care are of the utmost importance.
Recovery from a stroke begins in intensive care, from the moment vital functions are stabilized. A multidisciplinary rehabilitation team works with the patient, which includes a rehabilitation doctor, physical therapist or exercise therapy instructor, speech therapist, massage nurse, physiotherapist and physical therapy nurse, psychologist, occupational therapist, guard and rehabilitation nurse. Diagnosis is carried out using special scales that reflect the degree of dysfunction and limitations in the patient’s activity, the influence of environmental factors on the rehabilitation potential. The rehabilitation process continues throughout the entire period of hospitalization. At the second stage, patients with serious disabilities who are unable to move independently are sent to rehabilitation departments or specialized hospitals. Those who can walk independently or with support are rehabilitated in outpatient centers based in clinics and sanatoriums.

The rehabilitation process should not be interrupted, so classes must be continued at home. Of course, there are no high-tech robotic complexes or physiotherapeutic equipment at home, but exercise therapy, massage, and work with a psychologist, speech therapist and occupational therapist are possible. For this purpose, telemedicine technologies are used and visits to rehabilitation specialists are organized.

The individual rehabilitation program includes not only a referral for rehabilitation treatment, but also technical means of rehabilitation. However, usually relatives also have to devote significant physical and financial resources to achieve the best effect [7].

Prevention of strokes

Hereditary predisposition to stroke, the presence of cardiac diseases, pathology of blood vessels and blood composition, age over 40 years, obesity and diabetes require a number of preventive measures:

1. Maintaining normal blood pressure, taking antihypertensive drugs as prescribed by a doctor, monitoring blood pressure.
2. Maintaining a normal level of physical activity, exercise, walking 30-40 minutes a day (for example, walking the dog).
3. Conducting preventive examinations, including a standard set of laboratory parameters. During a preventive examination, the following tests are additionally required: gene diagnosis of CADASIL syndrome using the PCR method, plasma factors of the blood coagulation system, antibodies to prothrombin of the IgG and IgM classes to determine the risk of thrombosis, determination of polymorphisms associated with the risk of arterial hypertension, diabetes mellitus, lipid disorders exchange, in order to identify a predisposition to diseases that increase the risk of stroke, von Willebrand factor (a glycoprotein that ensures the formation of blood clots), complex laboratory tests for preclinical diagnosis of cardiovascular diseases are offered (“ELI-ANKOR-Test-12”, “Cardiorisk”).
4. Avoiding chronic and acute stress, maintaining mental hygiene.
5. Normalization of weight (BMI <25 kg/m2).
6. Healthy eating (for example, Mediterranean diet, limiting salt to 5 5 g/day).
7. Quitting smoking and taking psychoactive substances.
8. Treatment of diseases that are a risk factor for stroke [8, 11].

Who is at risk

There are people who need to be especially wary of developing a stroke, as they are at risk.

Among them:

• Persons with hypertension.
• Patients with diabetes.
• Men and women over 65 years of age.
• People with abdominal obesity.
• Persons with a hereditary predisposition to vascular pathologies.
• Patients who have previously had a stroke or heart attack.
• Patients with diagnosed atherosclerosis.
• Women over 35 years of age taking oral contraceptives.
• Smokers.
• People suffering from heart rhythm disturbances.
• People with high cholesterol levels.

Most often, patients with the listed diagnoses are registered at the dispensary. Special mention should be made of people living in a state of chronic stress. Emotional stress negatively affects all systems of the body and can cause a stroke.

Bibliography

1. Hemorrhagic stroke in adults: clinical recommendations of the Ministry of Health of the Russian Federation, 2016. Developers Association of Neurosurgeons of Russia. - Electronic text. - URB: (access date 08.18.2020).
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3. Ischemic stroke and transient ischemic attack in adults: clinical recommendations of the Ministry of Health of the Russian Federation, 2022 developers: All-Russian Society of Neurologists, National Association against Stroke, Association of Neurosurgeons of Russia, Association of Neuroanesthesiologists and Neuroreanimatologists, Union of Rehabilitologists of Russia. - Electronic text. - URB: ( access date 08/18/2020).
4. Machinsky P.A. Comparative characteristics of incidence rates of ischemic and hemorrhagic stroke in Russia / P.A. Machinsky, N.A. Plotnikova, V.E. Ulyankin [and others] – Direct text.// News of higher educational institutions. Volga region. Medical Sciences.- 2022.- “2(50)-P.112 – 132 DOI 10.21685/2072-3032-2019-2-11.
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7. Order of the Ministry of Health of the Russian Federation dated July 31, 2022 No. 788n “On approval of the Procedure for organizing medical rehabilitation of adults.” – URB: (date of access 08.17.2021).- Access mode: Electronic library system “Garant”. — Text: electronic.
8. Prevention of cerebrovascular accidents: textbook. manual / Compiled by: L.B. Novikova, A.P. Akopyan. – Ufa: Publishing house of the State Budgetary Educational Institution of Higher Professional Education BSMU of the Ministry of Health of Russia, 2015.-58 p.
9. Stakhovskaya L.V. Analysis of epidemiological indicators of recurrent strokes in the regions of the Russian Federation (based on the results of the territorial-population register 2009-2014) / L.V. Stakhovskaya, O.A. Klochikhina, M.D., Bogatyreva, etc.]. CONSILIUM MEDICUM, 2016, vol. 5, no. 9, p. 8-11.
10. Shamalov N. A. Analysis of the dynamics of the main types of stroke and pathogenetic variants of ischemic stroke / N. A Shamalov, L. V Stakhovskaya, O. A Klochikhina [and others]. Direct text. // Journal of Neurology and Psychiatry named after. S.S. Korsakov. Special issues. 2019;119(3-2):5-10. doi.org/10.17116/jnevro20191190325.
11. 1RRE Electronic edition. Updated daily Stroke Day is celebrated on October 29, 2022 URB: (accessed 08/17/2021).

Author:

Pugonina Tatyana Alekseevna, Therapist