Lacunar Ischemic Stroke ⋆ Heart Treatment

If a lacunar stroke occurs, the symptoms do not always become obvious. Many patients retain full hearing, vision, motor activity, which is explained by the normal state of the cerebral cortex.

The first signs of a lacunar stroke can be mild, due to which the violation is often detected with some delay.

Lacunar stroke often affects a person at night, in a dream. Before an attack, the patient may be disturbed by headaches, a rise in blood pressure. With the onset of the acute phase, these conditions often disappear, and the main symptoms appear several hours (days) after a stroke.

The characteristic manifestations of LI are:

  • symmetrical increase in muscle tone;
  • convulsive syndrome;
  • memory impairment;
  • problems with speech;
  • impaired coordination;
  • weakening of sensitivity;
  • paralysis of the oculomotor muscles;
  • tremor, twitching of the head;
  • weakness in the body (pava or the left half);
  • uncontrolled urination.

Symptoms of lacunar ischemic brain damage are observed in approximately 20 percent of patients. In most patients, the disease has no clinical manifestations and is often an accidental diagnostic finding during tomography.

Symptoms of the disease are combined into symptom complexes or syndromes. Neurologists distinguish about 20 syndromes, the most common of which are:

  1. Isolated motor syndrome. It occurs in 6 out of 10 patients with lacunar stroke. Patients complain of limitation of mobility in the limbs, violation of facial expressions. Symptoms are most often one-sided; they occur on the opposite side of the ischemic lesion.
  2. Isolated Sensitive Syndrome. With this version of the course, all types of sensitivity are disturbed in the patient. The patient ceases to recognize temperature, pain, tactile and other irritants. Sensitivity disappears completely or partially decreases.
  3. Atactic hemiplegic syndrome. Such symptoms are diagnosed in 10-12% of patients. It is characterized by weakness in the legs or arms, combined with impaired motor activity on the affected side.

In addition, the symptoms of the disease include:

  • violation of urination and defecation;
  • memory impairment;
  • slurred speech.

If any neurological symptoms appear, you should immediately seek specialized help. Early treatment will improve the patient’s condition and prevent the development of relapses.

Symptoms of a lacunar type stroke directly depend on the area of ​​the brain lesion. Permanent signs of a stroke are heart rhythm disturbances and high blood pressure.

Doctors distinguish the following groups of neurological signs of this pathology:

  1. Isolated motor syndrome (more than 50% of cases). The lesion is located in the inner capsule of the brain. Paralysis of the opposite half of the body is observed.
  2. Isolated sensory syndrome (5-10% of cases). It occurs during the formation of gaps in the zone of the ventral thalamic ganglion. The patient loses full or partial sensitivity of the body – limbs, head, torso. He ceases to feel pain, temperature of objects, touches, etc.
  3. Atactic hemiparesis (10-12% of cases). The damaged areas of the brain are the varolium bridge, the dorsal part of the inner capsule. This condition is characterized by impaired coordination of movements and weakness in the limbs on the affected side. Often there is a combination of this syndrome with loss of sensitivity (35-40%).
  4. Dysarthria, awkwardness of the hands (6-7% of cases). Lacunae are located in the layers of nerve tissue. Paralysis of the head, upper limbs may occur, problems with speech begin.

Less common signs of a lacunar stroke of the brain can be considered:

  • hyperkinesis;
  • coordinating syndrome;
  • pseudobulbar palsy;
  • involuntary urination and defecation;
  • biliary dyskinesia, etc.

tip insulta - Lacunar Ischemic Stroke ⋆ Heart Treatment

When lacunar formations are found in silent zones, the disease can be asymptomatic.

With this pathology, almost all functions of the cerebral cortex are preserved. This is due to the lack of lacunae formation on cortical structures.

Often a stroke of this type occurs during sleep. Seeking immediate medical attention will help to avoid many serious complications and death.

A timely examination will help to make the correct diagnosis and begin treatment. To detect the presence of cavity formations in the brain structures, their localization and shape, computer and magnetic resonance imaging (MRI and CT) are capable of. The picture of the disease becomes more pronounced a week after the attack. During this period, repeated diagnostics are carried out to confirm the diagnosis.

As already mentioned, lacunar ischemic stroke is characterized by the formation of gaps. They always form in the deep parts of the brain and are never localized in the cerebral cortex. In 80% of cases, foci occur in the white part of the brain, and in the remaining 20% ​​- in the cerebellum and brain bridge.

The size of the gaps ranges from 1 to 15 millimeters in diameter. In some cases, single lacunae merge with each other, forming grooves of larger sizes. According to sources, the lacunar type accounts for up to a quarter of all cases of ischemic stroke.

The mechanism of the attack is as follows:

  1. Frequently occurring jumps in blood pressure adversely affect the condition of perforating vessels. They lose their elasticity and often lipids are deposited in them, in other words, fats;
  2. The lumen in the vessels decreases and becomes insufficient for the passage of the required volume of blood. In some cases, the lumen is completely closed, and the blood loses the ability to pass through the vessel;
  3. The melt is broken, and the brain cells stop receiving enough oxygen;
  4. Gradual tissue necrosis occurs;
  5. At the site of necrosis, a gap appears in the form of a depression.

Due to the fact that pathology does not affect the cerebral cortex, visual, auditory, speech functions are almost never violated, or it happens very superficially. But motor and sensory functions undergo changes.

lakunarnyj ishemicheskij insult 1 - Lacunar Ischemic Stroke ⋆ Heart Treatment

The first symptoms from the onset of a pathological condition may appear within a few hours, but sometimes it takes several days. Signal the occurrence of a lacunar stroke can:

  • Severe headache;
  • Paresis of the limbs;
  • Impaired coordination of movements;
  • Uncontrolled acts of urination and defecation;
  • Decreased sensitivity in certain areas of the body;
  • Numbness of body parts while maintaining motor functions. This symptom is rare, not more often than in 5% of cases;
  • Deteriorating visual, speech function;
  • Low concentration of attention;
  • Decreased intellectual activity.

In view of the peculiarities of the course of the lacunar type of stroke, as well as the small size of the lesions, the last three of these symptoms, as a rule, are mild or moderate. Moreover, sometimes signs of pathology are completely absent. This condition can be called subclinical. Often the presence of lacunae is detected only during the autopsy.

Since lacunar ischemic stroke is a variant of cerebral infarction, it also manifests itself as signs of a microinfarction. Once the gray matter is not affected, nothing deadly alarming appears: neither paralysis, nor nausea, nor fainting can be attributed to senile age. And only careful observation reveals:

  • the appearance of symmetric hypertonicity of the muscles of the whole body (often with the development of bilateral convulsions);
  • deepening memory loss and impaired speech quality;
  • the appearance of disorders of coordination of movements (“fluttering gait”);
  • “Omissions” of feces and urine (due to the lack of control over the processes in these organs);
  • weakness in the muscles of the limbs of one half of the body;
  • disorders of sensitivity (pain, tactile) and thermoregulation of the body.

The most indicative combination of speech disorder and “awkwardness in the hand” that appeared after a night’s sleep. The indicated symptoms never appear all at once.

All symptoms of the pathological process are divided into two large groups:

  • general clinical signs – specific manifestations of a stroke, according to which most patients can be diagnosed;
  • disease syndromes – a typical combination of several disorders indicating the localization of the lesion.

Common clinical signs are:

  • mandatory presence of arterial hypertension in a patient;
  • usually, a lacunar stroke occurs in a dream, it is preceded by a headache, increased pressure;
  • immediately during a stroke, blood pressure is normal/slightly increased, there is no headache/mild, drowsiness, lethargy, or loss of consciousness;
  • speech, ability to read, count saved;
  • deterioration occurs gradually over several hours/days, often accompanied by a temporary improvement.
NameLocalization of the lesion
Purely motor stroke (50%) – paralysis of one half of the bodyInner capsule, bridge, sometimes radiant crown, brain leg, rarely – medulla oblongata
Purely sensitive stroke (5%) is a unilateral violation of all or most types of sensitivity: pain, temperature, tactileThalamus, less commonly the brain stem
Ataxic hemiparesis (10%) is an imbalance accompanied by dizziness only clockwise/counterclockwise. Accurate movements are poorly given to the patientBridge, inner capsule, brain stem
Sensitive-motor stroke (35%)Thalamus or inner capsule, less often – radiant crown, bridge
Awkwardness in the hand and dysarthria are problems with targeted, accurate movements of the hand, speech impairment: a person is poorly given the pronunciation of individual sounds of words because of the inability to control the facial muscles.Bridge, inner capsule
Hemichorea-hemiballism – uncontrolled unilateral waving of the arm, leg, head.Lenticular nucleus, caudate nucleus
Isolated facial muscle paralysis – the lower part of the face is skewed on one side, the mobility of the forehead (the ability to frown, raise eyebrows) is usually preserved.Radiant crown, inner capsule

The basic principles of treatment

Lacunar-type stroke doctors often call a heart attack. The main reason for its occurrence is considered to be a violation of blood circulation in the deep perforated arteries of the brain against the background of hypertension and systemic atherosclerosis.

lakunarnyj insult - Lacunar Ischemic Stroke ⋆ Heart Treatment

Small gaps form in areas of cerebral tissue damaged by ischemia. The average diameter of such cavities is 10 mm.

Lacunar infarction of the brain is often visible on the tissues of the cerebellum, white matter, internal capsule, bridge, thalamus.

The main causes of the pathology are high blood pressure and atherosclerotic changes in the blood vessels. Experts note that the disease can develop both at the height of the arterial crisis, and with a stable course of hypertension.

In addition, significant etiological factors:

  • congenital malformations of the cerebral vessels;
  • emboli resulting from myocardial infarction;
  • endocrine pathology;
  • conditions associated with increased thrombosis;
  • bad habits.

Timely treatment started can significantly improve the prognosis, without bringing the pathology to serious consequences. One of the main points in therapy is the correction of blood pressure. It is achieved by:

  • good rest;
  • reduce the number of stressful situations;
  • giving up bad habits;
  • normalization of the diet;
  • taking antihypertensive drugs.

Normalization of the level Blood pressure should be combined with the use of antiplatelet agents. They improve the rheological properties of blood and prevent the development of relapses.

Another area of ​​treatment for patients with lacunar ischemic stroke is the use of medications that improve blood microcirculation. Therapy begins parenterally with a gradual transition to oral administration.

To improve the condition of the nervous tissue, neurotrophics are used. They improve the supply of oxygen and nutrients to GM, stimulating recovery processes.

In addition to a specific appearance, the lacunar form of a heart attack differs from other varieties of stroke by a number of specific signs. The first is the small size of the lesion. The magnitude of lacunar strokes is from 1 mm to 1,5-2 cm. Occasionally, larger sections of a heart attack (more than 2 cm) are found, which are called giant.

Often the disease is multiple. In one patient, from several tens to hundreds of cavities can be found, giving the patient’s brain the appearance of a cheese head. Usually this anatomical picture is observed in the elderly, patients with diabetes mellitus. Multiple organ damage is the cause of senile dementia (dementia), Parkinson’s disease, extensive hemorrhage, pseudobulbar symptom.

Single gaps are also found, most often in women, young people (3).

The appearance of lacunae is associated with damage to small intracerebral arteries, which pass deep in the middle of the brain. Pathological cavities form around the affected vessel; therefore, the organ cortex does not touch. Due to which higher functions (speech, memory, intelligence) are rarely affected, other symptoms may be mild. This is the main reason why the disease is not always able to be diagnosed during life.

The occurrence of a stroke is always associated with arterial hypertension. Chronic exposure to high pressure causes various point injuries of cerebral vessels up to 1 cm long:

  • the death of cells of the artery wall, leakage of the lesion with fibrin (fibrinoid necrosis);
  • plasma exit from the bloodstream (plasmorrhagia);
  • impregnation of the vessel wall with a specific protein, making it look like a glass tube (hyalinosis);
  • replacement of connective tissue with artery wall;
  • fat deposition, usually without the formation of atherosclerotic plaques.

Nerve cells located around the affected artery begin to receive an inadequate amount of oxygen and nutrients. When their deficit becomes critical, neurons die off. Since time, a gap has been formed at the site of necrosis.

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Another mechanism of cavity formation is typical for heart attacks located at some distance along the main vessel. The middle layer of the artery consists of muscle cells – myocytes, which are destroyed by arterial hypertension. The vessel ceases to cope with the pumping of blood, its distant branches remain semi-empty, which leads to necrosis of neurons.

Occasionally, the death of neurons with the formation of gaps is caused by the rupture of tiny protrusions of the cerebral vessels (aneurysms). This form of the disease refers to hemorrhagic subtypes of cerebrovascular accident.

Arterial hypertension was previously thought to be the only cause of lacunar stroke. More thorough studies have shown that in some patients, cerebral infarction develops as a consequence of a combination of cerebral artery atherosclerosis, high pressure. But by themselves atherosclerotic lesions of the arteries, the nourishing brain rarely causes the formation of cavities.

Other risk factors for lacunar stroke (3):

  • diabetes mellitus type 2;
  • alcohol abuse;
  • smoking;
  • transferred micro strokes;
  • elderly age.

There are various possible factors for the occurrence of lacunar stroke. All of them, one way or another, are associated with the state of the cardiovascular system.

Arterial hypertension is considered to be the main reason for the initiation of a lacunar stroke of the brain. The more often pressure surges occur, the higher the risk of pathology, since each time the walls of the arteries stretch and lose their elasticity. This primarily concerns people who do not control the situation and allow a constant increase in pressure.

In addition to hypertension, the following can provoke the development of pathology:

  • Atherosclerosis;
  • Diabetes;
  • Arteritis;
  • Thrombosis;
  • Impaired carbohydrate metabolism;
  • Vasculitis;
  • Disturbed hematopoiesis;
  • Emboli arising from a heart attack, atrial fibrillation;
  • Chronic renal failure.

lakunarnyj insult1 - Lacunar Ischemic Stroke ⋆ Heart TreatmentDiabetes mellitus – a provoking factor in lacunar stroke

It is also noted that lacunar stroke can occur due to hemorrhages in adjacent tissues.

Currently, experts isolate a small, progressive and complete stroke that affects the human brain. Small has reversible neurological deficits. Basically, this type of pathology is diagnosed if the symptoms completely regress within 2 or 3 weeks. To date, according to statistics, this happens in 10 – 15% of cases.

In addition, there is also a progressive stroke, which is diagnosed if the degree of neurological deficit increases over time. In this regression of neurological disorders or their stabilization become signs of a completed or, as it is also called, an extensive stroke.

Lacunar stroke, which is a type of ischemic stroke, occurs in 15 – 30% of cases. The development of pathology begins in the formation of occlusion of the small vessels of the brain. Often the localization site is the subcortical nucleus.

At the place of localization, the stroke differs as follows: damage to the vascular and vertebrobasilar pool. Moreover, in the vascular pool is affected:

  • internal carotid artery;
  • front artery;
  • middle artery.

The defeat of the vertebrobasilar basin occurs through:

  • vertebral artery;
  • basilar artery;
  • cerebellum;
  • posterior cerebral artery;
  • thalamus.

First of all, tests are performed to identify the disease. In this case, arterial hypertension is immediately detected. After an attack, all symptoms may worsen over the next few days, often this time is limited to hours. That is why the patient is under the supervision of specialists all this time.

If the disease was detected as early as possible, then proper treatment will take effect and in the period up to 6 months all motor and other functions will be returned to the patient. For the diagnosis of pathology, CT and MRI are used. First of all, treatment is aimed at reducing pressure to normal and improving blood circulation.

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In the treatment of lacunar stroke, specialists use basic therapy. Differentiated treatment is not used, since there is no need for it. The principles of treatment are as follows:

  • metabolic and neuroprotective drugs are used;
  • during treatment, the goal is to improve blood circulation;
  • in addition, adequate therapy of the underlying disease of the vascular lesion is used, that is, the symptoms of vasculitis, diabetes, hypertension and atherosclerosis are eliminated.

Of particular importance is the number of treatments, namely the rehabilitation period. It is from its implementation that the full restoration of the functioning of all parts of the body depends.

Methods of therapy

Diagnosing a lacunar stroke of the brain is a complex process. A site with pathological changes is small, so even modern imaging techniques are not always able to determine it. Only an integrated approach to diagnosis allows you to make the right diagnosis. Specialists consider:

  1. Anamnesis. A patient with a suspected lacunar stroke has a history of hypertension, metabolic disturbances, and other risk factors.
  2. Complaints of the patient. This is the basic component of any diagnosis.
  3. The clinical picture. Symptoms of the disease can appear immediately in full or increase gradually, so there should be monitoring of the patient in dynamics.
  4. Biochemical blood parameters (increase in cholesterol, certain fractions of lipoproteins, blood glucose).
  5. An electrocardiogram that can detect heart rhythm disturbance and symptoms of myocardial infarction.
  6. MRI This instrumental method allows you to visualize the cavity in the brain tissue at different levels, to determine their shape and size.

Lacunar stroke treatment should only be carried out by qualified doctors. Self-medication in this case is strictly prohibited. In the acute period, the patient should be in a hospital setting. Since a lacunar stroke is closely associated with arterial hypertension, the therapy is usually carried out not only by a neurologist, but also by a cardiologist.

The basis for the treatment of lacunar ischemic stroke is drug therapy. Patients may be assigned:

  • Drugs that lower blood pressure. Example: Furosemide, enalapril;
  • Blood thinners and blood clots. The most striking example is Aspirin;
  • Drugs that eliminate existing blood clots. Example: Vrafarin;
  • Drugs that improve cerebral circulation. Example: Nootropil.

lakunarnyj insult3 - Lacunar Ischemic Stroke ⋆ Heart TreatmentFurosemide – a drug for the treatment of lacunar stroke

During treatment, constant monitoring of blood pressure is carried out.

Depending on the symptoms, additional medications, such as neuroprotectors, may be prescribed. Vitamin complexes will not be superfluous. They will help replenish the balance of essential nutrients in the body and strengthen the patient’s immune system.

No less important point in the treatment of lacunar ischemic stroke is rehabilitation. It, in combination with the right drug therapy, can help the patient recover as quickly as possible.

Modern diagnostics

The usual research methods – computed, magnetic resonance imaging are not always able to detect lacunar ischemic stroke of the brain, especially with a tiny size of lesions (less than 1 mm).

An experienced neurologist makes a diagnosis, localization of the lesion according to typical pathology markers:

  • characteristic clinical picture, medical history;
  • MRI does not reveal pathology, although the symptoms clearly correspond to a stroke. On the 7th day of the disease, lesions can be visualized;
  • deviation-free angiography;
  • the level of cerebrospinal fluid enzymes (creatine kinase, angiotensin converting, lactate dehydrogenase) is normal.

Stroke rehabilitation

The lacunar type of stroke necessarily requires rehabilitation after treatment. It can be aimed at restoring both physiological functions and psychological disorders, but most often it is complex. During rehabilitation, a rehabilitation doctor, physiotherapist, exercise therapy doctor, psychologist, speech therapist, and massage therapist can work with the patient.

The rehabilitation course may include:

  • Physiotherapy exercises. Unlike ordinary exercises, it includes specially selected exercises that are aimed at restoring certain muscle groups or joints;
  • Massotherapy. It is carried out with the aim of improving blood circulation and restoring the motor and sensory functions of the affected areas of the body;
  • Classes on simulators. In this case, also, as a rule, specialized simulators are used, and not of a general nature;
  • Physiotherapy procedures, for example: electrical stimulation, biocurrents.

If speech disturbances are nevertheless observed, then a speech therapist will need classes, but the patient’s family members themselves can play a major role in this, because the more they devote time to classes with him, the faster the results of rehabilitation will appear. Also, in many cases, classes are required to train concentration of attention, memory, and other mental activity.

Recovery of a patient after an experienced attack should take place only under the supervision of qualified specialists.

The consequences of a lacunar stroke are both motor and psychological disorders, so the rehabilitation of such patients should be comprehensive. It must be started as early as possible and carried out under the supervision of a specialist.

Motor rehabilitation is aimed at eliminating the negative consequences of the musculoskeletal system. Its goal is the restoration of movements in full. To do this, use:

  • special physical exercises;
  • electrical stimulation of the neuromuscular apparatus;
  • passive gymnastics;
  • classes on simulators.

The prognosis for early motor rehabilitation is positive. In most patients, the amount of motor activity in the affected limb increases.

Speech disturbance is a common consequence of a lacunar stroke. For the rehabilitation of such patients:

  • conduct classes with a speech therapist;
  • communicate with family.

Lack of speech isolation is a critical factor for positive rehabilitation. It significantly improves prognosis and increases the likelihood of restoring understanding and reproduction of speech.

Social rehabilitation is achieved by creating a favorable microclimate in the family, gradually involving the patient in homework, and an interesting hobby.

Probable consequences and forecast of specialists

If a lacunar single stroke was observed, then the forecasts of specialists are quite favorable. In general, after some recovery time after relapse, all functions return to the patient, although it is likely that sensitive residual and motor symptoms can still be observed.

With frequent relapses, there is a chance of developing a lacunar state of the brain, and the likelihood of this is very high. According to statistics, such a complication is observed in 65 – 70% of cases with repeated lesions.

But, despite the fact that the functions are restored, the lacunar stroke leaves an indelible imprint on the mental state of a person.

The mental state lends itself to gradual change. Thus, memory lapses, communication difficulties and disorientation are noted. The consequence of a lacunar stroke is tearfulness, a feeling of self-helplessness, the appearance of frequent tantrums and a state of affect are likely.

Of all forms of acute cerebrovascular accident with persistent symptoms, patients with lacunar stroke have the best prognosis. Death directly from the attack itself is extremely rare. According to a global study, only 3,5% of patients die in the first 1,78 years (4). The worst forecast are:

  • the elderly;
  • patients with diabetes;
  • high systolic pressure: every “extra” 20 mmHg increase the risk by 1,3 times;
  • low hemoglobin (less than 13 g/dl);
  • decreased filtration ability of the kidneys;
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Tatyana Jakowenko

Editor-in-chief of the Detonic online magazine, cardiologist Yakovenko-Plahotnaya Tatyana. Author of more than 950 scientific articles, including in foreign medical journals. He has been working as a cardiologist in a clinical hospital for over 12 years. He owns modern methods of diagnosis and treatment of cardiovascular diseases and implements them in his professional activities. For example, it uses methods of resuscitation of the heart, decoding of ECG, functional tests, cyclic ergometry and knows echocardiography very well.

For 10 years, she has been an active participant in numerous medical symposia and workshops for doctors - families, therapists and cardiologists. He has many publications on a healthy lifestyle, diagnosis and treatment of heart and vascular diseases.

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