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Acute cerebrovascular disorders

Determination of stroke

A stroke is an acute violation of the blood supply to the brain, characterized by sudden (within a few minutes, hours) by the appearance of focal and/or common neurological symptoms, which remains for more than 24 hours or leads to the death of the patient in a shorter period of time due to cerebrovascular pathology.

Mexidol® after a stroke is able to reduce the
development of the development and severity of the consequences of the disease.

Types of stroke:

1. Ischemic stroke is a damage to the brain, manifested by an acute violation of the local functions of the brain, which lasts more than 24 hours, or leads to death, or confirmed by neuroimaging and other objective research methods, caused by the insufficiency of blood supply in a certain zone of the brain as a result of a decrease in the brain blood flow, thrombosis or embolism associated with diseases of blood vessels, heart or blood.

2. Hemorrhagic stroke - hemorrhage in the brain caused by the rupture of pathologically altered walls of cerebral vessels or diapedue (sample blood cells through the vascular wall).

Both species have their own etiopathogenetic and clinical features.

A share of hemorrhagic stroke accounts for 20 % of all cases of acute cerebrovascular accident. Hemorrhagic stroke includes all forms of non -human
intracranial hemorrhage. The causes of hemorrhagic stroke can be hemorrhages due to the rupture of the aneurysm of the brain (pathological expansion of the lumen of the brain arteria, due to the thinning of the muscle layer of the vessel wall), as well as arteriovenic malformation (vascular development vice).

Breaks of aneurysm and malformations can lead to the formation of intracerebral hematomas or intraventricular hemorrhages. Separately isolated subarachnoid hemorrhage, which is characterized by the spread of blood from the bloodstream to the subarachnoid space (between the soft and spider shells) of the brain [1].

The most common type of acute cerebral circulation disorders (80 %) include ischemic stroke, which is due to the acute deficiency of blood supply to a certain area of the brain due to a decrease in cerebral blood flow, thrombosis or embolism [2].

If the patient has a short -term episode of a neurological deficiency caused by focal ischemia of the brain with clinical symptoms that last less than 24 hours, and there are no signs of acute brain infarction according to neuroimaging, we can talk about a transient disturbance of cerebral circulation or transient ischemic attack.

Currently, a generally recognized classification of pathogenetic subtypes of ischemic stroke is the classification of toast [3]. There are five pathogenetic subtypes of ischemic stroke: atherotrombotic, cardiemball, lacunal, a stroke of other established etiology, a stroke of unidentified etiology.

Atherotrombotic

16 % of all cases of ischemic stroke. It develops due to thrombosis of large arteries against the background of their atherosclerotic lesion. This subtype is diagnosed in patients with vascular stenosis of more than 50 % or occlusion of one of the main arteries of the head on the side of the affected hemisphere of the brain. According to computed tomography (CT) or magnetic resonance imaging (MRI), as a rule, a hemisphere heart attack is determined more than 1.5 cm in diameter.

Cardiemball

29 % of all cases of ischemic stroke. The pathogenetic subtype of ischemic stroke is diagnosed in patients with occlusion of cerebral arteries due to cardiogenic embolism. An important criterion is the presence of a cardiac source of embolism - heart valves prostheses, atrial fibrillation, mitral stenosis, infectious endocarditis, etc. According to neuroimaging, damage to the cerebral cortex, cerebellum or subcortical hemispherin heart attack is more than 1.5 cm in diameter.

Lacunary heart attack

16 % of all cases of ischemic stroke. It develops due to occlusion of the fine perforator artery. Neurousualization methods in this subtype of ischemic stroke the focus do not determine or reveal the presence of a subcortical or stem ischemic focus with a diameter of less than 1.5 cm.

Strokes of other installed etiology

3 % of all cases of ischemic stroke. Patients with rare diseases are observed-fibromascular dysplasia, vasculitis, Moy-Mojah disease, dissociation of cerebral
arteries, factory disease, etc. According to CT/MRI of the brain, a brain heart attack of any size and any localization is detected.

Stroke of unidentified etiology

36% of all cases of ischemic stroke. They determine in patients with incomplete examination, with an unidentified cause of ischemic stroke, as well as in patients with two or more potential causes of stroke.

Stroke
(periods of the disease) ^[4]

The acute period is the first 3 days;
Acute period - up to 28 days;
early recovery period - up to 6 months;
Late recovery period - up to 2 years;
The period of residual phenomena - after 2 years.

Epidemiology

In 2019, 12.2 million cases of stroke were registered in the world, of which 6.55 million with a fatal outcome. It is important to note that despite the improvement of examination and treatment methods, the number of strokes and deaths against the background of a stroke continues to grow [5]. Previously, a stroke was considered a disease found in people of an older
age group, however, its frequency in young ones has been growing since the 1980s [6]. This is partly due to the improvement of neuroimaging methods, as well as the increased
prevalence of risk factors for cardiovascular diseases, for example, an increase in the use of prohibited substances by persons younger than 45 years.

The frequency of a stroke in patients under 45 years old is from 3.4 to 11.3 per 100,000 population per year [7]. The ratio of ischemic strokes to hemorrhagic was 5: 1. The average age of stroke is 66.7 years (63.7 years in men and 69.4 years in women). The absolute number of strokes in patients under the age of 67 is higher in men, and at an older age higher in women [8]. Hemorrhagic stroke is 10–20 % of all types of cerebrovascular accident. In the Russian Federation, a hemorrhagic stroke is diagnosed every year in 43,000 people. The average age of patients is 60–65 years [9].

Pathogenesis of ischemic stroke

Ischemic stroke develops due to a sudden decrease in blood flow of a certain area of the brain as a result of occlusion of the artery that feeds it is most often a thrombus or embolus. In the center of the ischemic zone, an irreversible focus of necrosis (infarction) is formed, surrounded by a zone of ischemic partial shade (penumbrea), which retains its ability to
functional restoration. A focus of necrosis is a zone of irreversible changes, completely devoid of blood supply, including collateral. The elimination or decrease of the zone
of necrosis (heart attack) is possible only with the destruction or removal of the occlusion vessel of the cause using thrombolytic therapy or thromboexstation in the time
interval of the “therapeutic window” of 24 hours. Penumbra is a pathogenetic basis of any subtype of ischemic stroke. Neurons of the Penumbres experience
an energy deficit state against the background of microcirculation disorders [10]. A decrease in blood flow in the Penumble to subcritical values is launched by a multi -stage cascade of metabolic
disorders, or an ischemic cascade, including complex multi -stage changes, in which the activation of free radical oxidation plays a significant role, the damaging
effect of active forms of oxygen, leading to the development of oxidative stress.

Against the background of oxidative stress, the structural components of the cell are damaged: lipids, proteins and nucleic acids [10, 11]. After the cessation of blood flow or its decrease to critical values, there is a significant increase in the formation of free radicals, significantly exceeding the possibilities of their own antioxidant protection of the body [12]. Oxidative stress exacerbates reperfusion, which is accompanied by the intensification of free radical oxidation in the Penumbra region [13]. Thus, the main “target” of therapeutic influences in the process of treating ischemic stroke is the Penumbra zone. The optimization of energy processes in this zone will help reduce the severity of neurological deficiency and improve vital functions.

Diagnosis of stroke

The diagnosis is based on a thorough study of the anamnesis, the identification of risk factors and the analysis of clinical data, namely neurological symptoms. The clinical picture of strokes is diverse and is largely determined by the vascular pool of the brain catastrophe, and its character (ischemia or hemorrhoids) [14].

Data of the clinical examination, especially at the stage of the debut of the disease, does not allow to reliably establish a hemorrhagic or ischemic type of stroke. Nevertheless, signs that are more characteristic of the ischemic and hemorrhagic types of stroke are distinguished (tab. 1).

Sign

Start

Symptoms-"harbinger"

Symptoms prevail

Neuroimaging data

Ischemic stroke

Sharp or gradual, sometimes with an increase in several hours or even a day. The start of events is more often in the morning, during and/or after sleep. Often occurs due to a sharp fall in blood pressure

Visual disorders, weakness in the limbs, common symptoms (dizziness, headache, nausea)

Focal (depending on the ischemia zone), for example, monoparesis or hemiparesis, hypesthesia (hemigipesthesia), ataxia (hemiathaxia), dysarthria, cognitive disorders, etc.

On CT or MRI visualized the zone of cerebral infarction is

Hemorrhagic stroke

Sudden, sharp. The high numbers of diastolic blood pressure (DDAD) are preceded by above 120 mm Hg. Art.

Feeling of “tide” of blood to the face, “redness” of the field of view. Intense attack of headache, pain in the neck

Permanent (violation of consciousness up to a coma, convulsive attacks, respiratory disorders, arrhythmia, vomiting, severe headache)

On CT or MRI, intracranial hemorrhage is visualized

Table 1. Clinical-neurovibialization differences of the ischemic and hemorrhagic types of stroke

If a stroke is suspected, emergency hospitalization and specialized assistance are needed. In order to differentiate the form and determine the treatment tactics, an emergency (within 40 minutes from the moment the patient enters the hospital) is carried out by an subordinate CT or MRI of the brain [15, 16]. These methods make it possible to exclude acute intracranial hemorrhage, as an absolute contraindication to subsequent thrombolytic therapy and/or thrombexstation in the first hours of a stroke [2].

At the same time, CT and MRI with intracranial hemorrhage allow you to clarify its location and volume [1]. To objectify the patient's condition with a ischemic stroke, in the dynamics of the process and the outcome of the stroke, by 21 days in the hospital, the scale developed by the American National Institute of Health (National Institutes of Health Stroke Scale - NiHSS) [17]. To control the effectiveness of the rehabilitation process, assess the independence and disability of the patient with a stroke and its consequences, the modified Rankin (MSHR) scale is actively used [18].

Stroke and prevention risk factors

The risk factors of stroke include: arterial hypertension, heart disease, atrial fibrillation, myocardial infarction, dyslipoproteinemia, diabetes mellitus, asymptomatic damage to the carotid arteries, hereditary predisposition, smoking, low level of physical activity, malnutrition, abuse of alcoholic drinks, impaired liver function, accompanied by liver function, accompanied changes in the hemostasis system, prolonged psycho -emotional stress or acute stress.

Primary prophylaxis of stroke - a set of measures aimed at reducing the influence of existing risk factors (rejection of bad habits, monitoring and maintaining targeted arterial pressure, treatment of diabetes, etc.).

Secondary prevention should begin as quickly as possible: immediately after the diagnosis of a transient ischemic attack or no later than 48 hours after the development of ischemic stroke. As a result, you can reduce the risk of re -violation of cerebral circulation by 20-30 %. The main directions of the secondary prevention of ischemic stroke are aimed at correction of risk factors and include non -valley methods (modification of lifestyle), drug therapy (antihypertensive, antitrombotic drugs, lipidemic therapy) and surgical treatment methods [2].

The consequences of a stroke

Stroke is one of the main reasons for the disability of the population (3.2 per 1000 population). According to the National Stroke Register, 31 % of the patients who have suffered a stroke need outside help to care for themselves, 20 % cannot go on their own. Only 20 % of surviving patients can return to their previous work. In patients who have undergone ischemic stroke, the risk of developing repeated strokes is almost 10 times increased and is about 25-30%. In Russia, in 2019, 445,959 cases of stroke were registered (while the coefficient standardized by age decreased by 28.1 %), mortality - 327,885 cases, prevalence - 3 020 719. [19]. The mortality in patients with hemorrhagic stroke reaches 40-50 %, and disability develops in 70–75 % survivors. [9].

The consequence of a stroke is a persistent neurological deficit, the severity of which determines the functionality of the patient, the level of his social adaptation. The intake of Mexidol® after a stroke is able to reduce the likelihood of development and severity of violations.

Treatment and rehabilitation

Therapeutic and rehabilitation measures in patients who have undergone stroke are primarily aimed at preventing the further development of vascular disaster. Two main directions in the treatment of stroke are distinguished - differentiated and basic. The first depends on the type of stroke (hemorrhagic or ischemic), the size of the focus, the time that has passed from the onset of the disease, related diseases. The second provides support for the vital functions of the body (stabilization of blood pressure, control of the respiratory function, preventing edema of the brain, maintenance of hemostasis). Medical assistance in a stroke is conservative and surgical. An important component of effective assistance to patients with ischemic stroke is timely reperfusion therapy [20]. With ischemic stroke, it includes thrombolytic therapy, mechanical thrombectomy, as well as other less common methods [21]. It is recommended to start intravenous thrombolytic therapy as quickly as possible [22]. According to international recommendations, the time from the patient’s entry into the hospital before the start of thrombolytic therapy should not exceed 60 minutes (time from the door to the needle).

Surgical intervention in hemorrhagic stroke is carried out in the presence of hematoma of subcortical localization with a volume of more than 30 cm3 or in the cerebellum area of more than 10-15 cm3. The choice of the method of surgical intervention (open, endoscopic, etc.) depends on many factors: localization of the hematoma, somatic state of the patient, the presence or absence of a pronounced dislocation syndrome, etc. There are several methods of rehabilitation: motor rehabilitation, restoration of pelvic functions, cognitive rehabilitation, psychological recovery . The choice of rehabilitation methods depends on the type of stroke and type, as well as the severity of violations that occurred as a result of a vascular disaster. The faster rehabilitation begins, the higher its effectiveness and the more likely to restore the patient. The rehabilitation process should be carried out by a multidisciplinary brigade, including doctors of various specialties.

The effectiveness of the drug Mexidol® in the treatment of stroke

As a result of the development of ischemic stroke in the brain zone with impaired blood supply, primarily in the Penumble, an ischemic cascade is launched, including complex multi -stage changes, in which the activation of free radical oxidation plays a key role, the damaging effect of active forms of oxygen, which leads to the development of oxidative stress. This determines the importance of using neurocytoprotectors in the therapy with a multimodal action mechanism with an extensive evidence base, high performance indicators and good tolerance [10]. One of these proven drugs that affect the main links of the ischemic cascade is Mexidol® (original ethylmethylhydroxypyridine succinate) [11]. Below are the results of studies on this drug, including an assessment of its effectiveness and safety, as well as information on how to take Mexidol® after a stroke. Mexidol® confirmed its effectiveness and safety in numerous studies. With a stroke, Mexidol® presented high efficiency and safety in the acute, acute and early recovery periods during randomized controlled studies with the highest level of evidence.

The use of Mexidol® in the acute period of ischemic stroke at the prehospital stage, followed by thrombolytic therapy, has a positive effect on a decrease in neurological deficiency, regardless of the severity of the disease [23]. According to a randomized double-blind-controlled study of the effectiveness and safety of the Mexidol® drug, a reliable clinical confirmation of the effectiveness of the drug was obtained in the integrated therapy of ischemic stroke. The special effect was seen with its early purpose (in the first 6 hours), its antioxidant and antihypoxic effects are also proved and confirmed [24]. Mexidol®, with a stroke in the acute period, significantly reduces the content of lactate and inositol both in the zone of irreversible necrosis and in the penumble. This confirms the ability of the drug to stimulate aerobic processes in cells in ischemia [25]. Mexidol®, after a stroke, according to a randomized double-cententer placebo-controlled study in parallel groups with patients in acute and early recovery periods (Epica), showed a reliable decrease in symptoms and functional disorders in patients with half-step ischemic stroke.

Patients during the study received consistent (injection, then tablet) therapy with Mexidol®.

Go to the study of epic

P> During the therapy, a reliably more pronounced improvement of vital functions, measured according to MHR, was noted. There was also a decrease in the severity of the neurological deficiency by NIHSS compared to placebo in a group of patients taking Mexidol®. The appointment of Mexidol® after a stroke and its inclusion in basic therapy contributed to a faster stopping of depressive disorders, improving the quality of life. The safety of long -term sequential therapy in patients with ischemic strokes in the acute and early recovery periods, comparable to placebo [26], has been proven. In this study, the effectiveness of the drug Mexidol® on all the scales used did not differ depending on age. In patients 60–75 years with an ischemic stroke with related diabetes, a greater improvement in the quality of life was noted compared to the placebo group. In patients 76–90 years in the Mexidol® group, a significant increase in the share of patients with lack of problems with movement and self -care at the time of the end of therapy was observed. In subgroups of 60–75 years with concomitant diabetes and 76–90 years, against the background of taking Mexidol®, a reliable increase in the share of patients with lack of problems with everyday life is shown [27]. About how to take Mexidol® after a stroke, we will talk further.

In the prospective comparative open -controlled study of the effectiveness of the drug Mexidol® regarding the secondary prevention of stroke in 3400 patients, a decrease in the frequency of repeated ischemic strokes was shown over 5 years. The indicator remained such as in patients without concomitant pathological conditions, and in patients with arterial hypertension, obstructive apnea/hypnea syndrome, vasculitis, diabetes mellitus, atrial fibrillation and metabolic syndrome [28]. It is proved that Mexidol® in a stroke increases the resistance of cells and hypoxia tissues and oxidative stress, which reduces the damaging effect and increases the survival of neurons. Currently, Mexidol® is included in the current clinical recommendations “ischemic stroke and transient ischemic attack in adults” 2024. Thus, the feasibility of using the drug Mexidol® was proved at all stages of restoration treatment of patients underwent stroke.

Application scheme

How to take Mexidol® after a stroke?

The recommended sequential therapy scheme for patients with ischemic stroke: 500–1000 mg iv for 14 days, then Mexidol® Fort 250 1 tablet 3 times a day 2 months [11, 29]. For the purpose of the secondary prevention of stroke, it is recommended 2-3 times a year of consistent therapy courses Mexidol® 500 mg (10 ml) in/V for a drop for 14 days, then Mexidol® Fort 250 1 tablet 3 times a day for two months [ 11].

Block of articles on this topic

The effectiveness and safety of Mexidol in patients of different age groups in the acute and early recovery periods of the hemispherical ischemic stroke (the results of subanalysis of a randomized double blind multicenter placebo-controlled epic study)

The effect of therapy with the drug Mexol on the regression of neurological deficiency and a functional outcome in patients with ischemic stroke: a systematic review and meta analysis

Authors:
I.A. Voznyuk ^1.2 , S.V. Kolomensev ^2.3 , E.M. Morozova ¹

Treatment of patients with ischemic stroke in the vertebral-baslar system in the acute period: Experience in the use of the neuroprotective drug Mexidol

Authors:
Z.A. Goncharova, I.V. Chernikova, V.A. Nazarova, V.V. Tolmacheva, K.G. Ovsepyan
FSBEI in "Rostov State Medical University" of the Ministry of Health of Russia, Rostov-on-Don, Russia

Oxidative stress in the pathogenesis of cerebral stroke and its correction

Authors:
M.Yu. Martynov ^1.2 , M.V. Zhuravleva ^3.4 , N.S. Vasyukova ⁵ , E.V. Kuznetsova ⁶ , TR Kameneva ⁷

Study of the effectiveness and safety of the sequential use of Mexidol and Mexidol Forte 250 in the treatment of patients with acute ischemic stroke

Authors:
S.M. Karpov ¹ , M.Yu. Morozova ² , K.A. Muravyov ² , I.A. Prisilova ¹ , F.S. Kantemirova ³

Vascular inflammation based on the development of atherotrombotic stroke

Authors:
A.V. Romanenko, I.P. Amelina, E.Yu. Soloviev

FGAOU in Russian National Research Medical University named after N.I. Pirogov »Ministry of Health of Russia, Moscow, Russia

The effectiveness and safety of the use of ethylmethylhydroxypyridine of succinate in patients with acute ischemic stroke

Authors:
M.V. Zhuravleva ^1.2 , I.A. Schukin ³ , M.S. Fidler ³ , A.B. Prokofiev ^1.2 , S.Yu. Serebrova ^1.2 , N.S. Vasyukova ⁴ , E.Yu. Demchenkova ¹ , V.V. Arkhipov ¹

Study of the effectiveness and safety of the drug Mexol Fort 250 as part of consecutive therapy in patients with a hemisphere ischemic stroke in acute and early recovery periods

Authors:
M.A. Loskutnikov, M.A. Domashenko, T.M. Vakin, I.A. Trushina, V.I. Konstantinov, O.S. Proskuryakova, E.P. Schukina

The effectiveness of the use of ethylmethylhydroxypyridine of succinate in the restoration treatment of patients who have undergone ischemic stroke

Authors:
M.V. Zhuravlev ^1.2 , A.B. Prokofiev ^1.2 , V.V. Arkhipov ¹ , S.Yu. Serebrova ^1.2 , G.I. Gorodetskaya ^1.2 , O.A. Demidova ¹

¹ FSBI “Scientific Center for Expertise of Medical Application” of the Ministry of Health of Russia, Moscow, Russia;
² FGAOU VO "First Moscow State Medical University named after THEM. Sechenov "Ministry of Health of Russia (Sechenov University), Moscow, Russia

Features of the treatment and rehabilitation of patients who suffered Covid-19 with ischemic stroke

Authors:
G.S. Rakhimbayeva, Sh.R. Gazieva, M.K. Atyaniyazov, F.Kh. Muratov, D.S. Tolipov, U.D. Shodiev

Tashkent Medical Academy, Tashkent, Republic of Uzbekistan