Brain infarction

Strokeis acute disorders of cerebral circulation, rapidly developing clinical signs of focal (at times global) disturbance of cerebral function, lasting more than 24 hours or leading to death with no apparent cause other then that of vascular origin

According to World Health Organization classification all cerebrovascular diseases are

divided into 3 groups:1. Premonitary and initial symptoms of brain blood supply

insufficiency2. Acute cerebral blood circulation disturbancesa) Dynamic cerebral blood circulation disturbances• Hypertonic crisis • Acute hypertonic encephalopathyb) Strokes: Haemorrhage • subdural, epidural• intracerebral haemorrhage• ventricular hemorrage Ischemic• Brain infarction (nonembolic)• Brain infarction (embolic)• Brain infarction (thrombotic)

According to World Health Organization classification all cerebrovascular diseases are

divided into 3 groups:

3. Dyscirculative encephalopathy or chronic cerebral blood circulation insufficiency or slowly progressive insufficiency of cerebral blood circulation

• I st• II st• III st• Dyscirculative myelopathy or chronic

spinal blood circulation insufficiency

Brain infarction

Classification

• Athetothrombotic

• Cardioembolic

• Hemodynamic

• Lacunar

• Haemorhoeological

Lacunar stroke

Penumbra

Center of infarction

Penumbra

Brain tissue, which we can save Благодаря любезности J. Saver

Penumbra

Penumbra

The most common causes of brain infarction

• Atherosclerotic lesion of MAH• Combination of atherosclerosis with

hypertension• Chronic ischemic heart disease with rhythm

disorders• Combination of atherosclerosis with diabetes• Rheumatism, heart abnormalities (inborn and

acquired)• Vasculitis

• penumbra

Pathogenetic mechanism of atherotrombotic ischemic stroke

Atherotrombosis and microcirculation

Adapted from: Topol EJ, Yadav JS. Circulation 2000; 101: 570–80, and Falk E et al. Circulation 1995; 92: 657–71.

Microvascular embolismEmbolism

Clinical features

Acute period of brain infarction is divided into three stages:

• Precursors

• Apoplectic stroke

• Focal signs

Clinical features• Precursors - transient ischemic attacks in the same

region where brain infarction is developed. Gradually during several hours focal neurologic symptoms are developed.

• The prevalence of focal symptoms over the general cerebral ones.

• General cerebral symptoms manifest as - Headache- Vomiting- consciousness disordersFocal symptoms depend on localization of the infarction,

damaged vessel and state of collateral blood circulation.

Territory of Middle cerebral artery

Middle cerebral artery

• Hemiplegia• Hemianesthesia• Gaze paresis• Speech disorders (motor, sensory, total aphasia) • Apracto – agnostic syndrome (lesion is right hemisphere) • Hemianopsia• Apraxia• Alexia• Acalculia • Anozognosia, and autotopognosia (lesion is right

hemisphere) • Astereognosis• Agraphia

Infarction in main branch of middle cerebral artery

CT scan

• Infarction in right parietal-occipital region (posterio branch of middle cerebral artery

Postischemic cist

Postischemic cist

Postischemic cist

Anterior cerebral artery• Spastic hemiparesis with the prevalence in

proximal part of upper extremity and distal part of lower extremity

• Symptoms of oral automatism • Psychiatric disorders• Dysphagia• Dysphonia• Astasia, abasia• Motor aphasia• Retention of urine.

Infarction in anterior cerebral artery

Haemorrhagic transformation

Posterior cerebral artery

• Hemianopsia

• Visual agnosia

• Hemianesthesia

• Hyperpathia

• Desorientation in space and time

• Optical gnosis

Postischemic cist

Territory of Vertebral artery

Vertebral arteryIn case of extracranial lesion:• systemic dizziness• Hearing disorders• Visual disorders• eye movements disorders• Vestibular and equilibrium disorders • paresis with sensory disturbances in extremities• some patients have “ drop- attacks “.

Basilar artery• loss of consciousness• eye movements disorders• pseudobulbar syndrome • tetraplegia • muscle tone disturbance• cerebellar symptoms • cortical blindness • vital functions disorders.

Diagnostics of Brain Infarction

The main peculiarities are:

• Before stroke period in the previous history ( TIA in anamnesis )

• The beginning of the stroke is gradual

• Data of somatic and neurological status

• Additional methods of diagnostics

Diagnostics of Brain Infarction

The main peculiarities are:

• Before stroke period in the previous history ( TIA in anamnesis )

• The beginning of the stroke is gradual

• Data of somatic and neurological status

• Additional methods of diagnostics

Diagnostics of Brain Infarction

• Rheologic disturbances• Liquor is pellucid, without significant changes. • EEG - There is focus of pathologic activity• USG finds out occlusion, stenosis of carotid and

vertebral arteries• CT reveals hypodensive focus on the second

day • MRI helps to find out small focuses and those,

located in the brain stem

Stenosis of internal carotid artery

•1- PCA, 2- ICA, 3- syphone of ICA, 5- CCA.

Адаптовано з E.Topol. Atlas of Atherothrombosis.- 2005

Strokes treatmentNondifferential treatment includes:• Prevention and treatment of pulmonary

insufficiency • Liquidation of heart – vascular disorders• Brain edema treatment• Normalization of water – electrolytes balance

and acid – alkali balance• Osmosis correction• Improving of brain metabolism• Liquidation of hyperthermia and other

autonomic disorders

Differential treatment of brain infarction

• To renew blood circulation in zone of ischemia

• To correct rheologic and coagulative properties of blood, to improve microcirculation

• To prevent disorders of cerebral metabolism

• To decrease brain edema• To treat brain hypoxia

To renew blood circulation in zone of ischemia

– Actilaza 100 mg I / v by drops every 2 – 3 hours.– Inhibitors of glutamat excretion ( difenin, nimotop,

MgSO4) are used. Nimotop is used 15 mg in 1500 ml of physiologic solution i/v by drops, or in tablets 30 – 60 mg 4 times per day.

• In order to improve perfusion we use cavinton 20 mg I /v by drops

• At hyperperfussion we use • euphyllini 10 ml 2.4 % solution, • penthoxiphyllini, • diuretics ( manitol 15 % 100 – 200 ml ) , • albumini 100 ml I / v.

To improve microcirculation

anticoagulative therapy :• heparini 5 000 U 4 times per day during 5 – 7 days, the

2 500 U during next 3 –4 days.• Fraxiparini is considered to be even more effective .Antiagregants are used also :• penthoxiphyllini 5 – 10 ml 2 % solution I /v by drops

during 10 days, then 200 mg 3 –4 times per day up to 1 month.

• Sermioni 4 mg I / v by drops during 10 days , then 1 tablet 3 times per day up to 1 month.

• Ticlid 250 mg twice a day.• Aspirini 250 mg once a day.• Dipiridamoli 1 – 2 ml i/v by drops during 10 days , then

25 mg 2 –3 times per day.