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Other causes of ischemic stroke (cerebral infarction)

Venous sinus thrombosis

Thrombosis of lateral or sagittal venous sinuses, as well as small cortical veins of the brain appear on the background of the following reasons:

  • septicemia ("blood infection")
  • intracranial infection (meningitis) due to otitis media, inflammation of the sinuses, open brain injury
  • states, accompanied by increased clotting (hypercoagulability), including polycythemia, sickle cell anemia during pregnancy or oral contraceptive pill

Venous thrombosis lead to increased intracranial pressure, arching headaches and focal neurological symptoms (focal seizures, paresis, paralysis, etc.). Massive infarction of the parenchyma of the brain (ischemic strokes) with secondary edema may prove his fatal for the patient, including a gross form of dislocation syndromes midline structures or brain stem, with its pinched under the edge of the cerebellum at the gallop tentorial opening.

Thrombosis of venous sinuses, may increase intracranial pressure and cause cerebral infarction.

Systemic hypotension

Systemic hypotension as a result of attacks of Morgagni -Adams- Stokes and other factors can sometimes lead to ischemia of the distal stenosis (narrowing of the lumen of the artery). Cerebral infarction (ischemic stroke) occurs only in long-term persistence of hypotension, such as cardiac arrest. Cerebral infarction (ischemic stroke) have a tendency to localize in the remote (distal) segments of large intracranial arteries, including distal zones pools of blood supply secondary, anterior and posterior cerebral arteries. That's what caused the development of cerebral infarction (ischemic stroke) in areas adjacent blood supply and the average anterior or middle and posterior cerebral arteries. In favor of this diagnosis showed weakness in proximal and distal extremities parietal deficit.

 

Intracranial and extracranial arteries dissections (internal carotid or vertebral arteries)

Stratification of the walls of major arteries of the neck with subsequent impairment of arterial blood flow in them can cause cerebral infarction (ischemic stroke). Often the separation of the arteries is a cause of stroke in children and young adults. When the walls of the artery divides bundle tunica media of the vessel or intima is separated from the media. Transient ischemic attack (TIA) and cerebral infarction (ischemic stroke) occur when blockage of the vessel or when the separation of the arteries causing embolism.

MRI shows a hematoma after separation the left internal carotid artery, accompanied by flushing and sweating in the patient.

A significant number of cases of separation of the arteries of the brain and neck caused by the transferred patients had head trauma and neck. Trauma can be as large and mild. Spontaneous stratification of arterial wall may occur in atherosclerotic lesions of her as a complication of fibro- muscular dysplasia or gomotsisteinurii, arteritis. Frequently observed separation of internal carotid artery wall, but he was also exposed to vertebrates and the main artery, the trunk of the middle cerebral and anterior cerebral artery.

Dissection of the internal carotid artery wall leads to paralysis or okulosimpaticheskomu Syndrome Horner's, when the patient arises ptosis, miosis and enophthalmos. More than 50% of the bundles of the internal carotid artery wall leads to the appearance of listening to the noise by the patient arterial blood. There may be tenderness over the carotid bifurcation bulb.

These symptoms and transient blindness in one eye or transient ischemic attack (TIA) often precede embolic cerebral infarction (ischemic stroke) or heart attack in the area adjacent to the blood supply to the carotid system. This leaves time for therapeutic intervention. However, the mechanism of formation of stratified lesions of the neck vessels and brain is so uncertain that adequate medical care by medical personnel is problematic.

Therapeutic approaches to bundle carotid wall in the neck include surgical removal and examination of stratified cluster and the intima with Fogarty catheter or medical treatment with anticoagulants and antiplatelet agents. When a patient with aortic carotid wall mark okulosimpatichesky paralysis (Horner's syndrome), or small stroke (TIA), it is preferable to holding anticoagulation therapy with warfarin. Surgical examination is recommended for patients whose weight increases transient ischemic attack (TIA) or marked progression of small strokes. After stabilization of neurological symptoms in such patients prescribed warfarin sodium for 6 months.

MRI shows a right vertebral artery dissection (white arrow), accompanied by a stroke in the brain stem (the medulla, black arrow).

Patients with symptomatic bundle vertebral, middle cerebral or posterior cerebral artery in the acute phase of illness can also recommend heparin, and later - warfarin sodium.

 

Cervical arteries fibromuscular dysplasia

Fibromuscular dysplasia of the arteries of the neck are more common in young women. In the carotid or vertebral arteries with multiple segments exhibit annular narrowing alternating with areas of dilation (expansion). Artery occlusion in fibro-muscular dysplasia is often incomplete. The process of occlusion of the lumen of the artery are asymptomatic, but sometimes it is accompanied discernible noise, transient ischemic attack (TIA) or stroke. Arterial hypertension (hypertension), if any, may be a consequence of renal artery stenosis.

The cause and progression of the disease (etiology and pathogenesis) of fibro- muscular dysplasia is not installed. If the clearance of the remaining portion of the artery narrowed more than 2 mm, then associate the disease with symptoms of transient ischemia (microstroke) or embolic stroke with caution. Surgical enlargement (dilatation) of the cervical internal carotid artery in cases with available clinical technically possible, but with a high risk of complications. In patients with transient ischemic attack (TIA), which is characterized by increasing severity of clinical manifestations, more effective (compared with surgical treatment) may be treated with anticoagulants.

 

Arteritis

Currently arteritis caused by bacterial infection or syphilitic, is not a common cause of thrombosis of the brain, as it was earlier in dopenitsillinovuyu era. Other arteritis is also rare, but any of them can cause thrombosis of cerebral vessels.

 

Necrotizing (or granulomatous) arteritis

Necrotizing or granulomatous, arteritis occurs both independently and simultaneously with generalized periarteritis nodosa or Wegener's granulomatosis. It affects the small distal branches (diameter less than 1 mm) of the main intracerebral arteries and causes heart attacks and ischemic small in the brain, optic nerves and spinal cord. Necrotizing or granulomatous, arteritis - a rare disease characterized by a steady progression. In some patients, effective steroid therapy (prednisone at a dose of 40-60 mg per day). In recent years, began to use drugs that suppress the immune system (immunosuppressants), and thus obtained favorable results.

 

Idiopathic giant cell arteritis (Takayasu’s arteritis)

Idiopathic giant cell arteritis, which affects large blood vessels leaving the aortic arch (Takayasu's arteritis), can in rare cases cause the carotid thrombosis or vertebral arteries. This uncommon cause of aortic arch syndrome in the population in the western hemisphere.

 

Temporal (giant cell) arteritis

Temporal arteritis is often diagnosed in older people. When the temporal artery is affected system external carotid arteries, especially the temporal branch, which develops subacute granulomatous inflammation with exudate. Exudate in the temporal artery soderzht lymphocytes, monocytes, neutrophils and giant cells. Usually the most affected areas of the arteries thrombosing. The main complaint by the patient's temporal arteritis is headache. For systemic manifestations are as anorexia, weight loss, malaise, and polymyalgia rheumatica (a common fibromyalgia or muscle pain). On the inflammatory nature of temporal arteritis indicate one or more of the following:

  • increase in body temperature
  • moderate leukocytosis
  • ESR acceleration
  • anemia

Blockage of the branches of the ophthalmic artery in the temporal artery leads to blindness in one or both eyes for more than 25% of patients. Sometimes the mark ophthalmoplegia with involvement of the oculomotor nerve. In some cases, the postmortem study found arteritis of the aorta and its major branches, including the carotid, subclavian, and femoral arteries of coronary. Severe inflammation in intracerebral arteries (arteritis) is rare. Sometimes it leads to stroke due to occlusion of the internal carotid, middle cerebral or vertebral artery. The diagnosis is based on the detection of arteritis tenderness thrombosed or thickened cranial arteries and confirmed the nature of lesions in the study of biopsy.

Used in the treatment of temporal arteritis corticosteroids provide a striking subjective improvement of the patient and often prevent the occurrence of blindness. More often than prescribed prednisone (prednisone). The course of treatment arteritis begins with application of large doses (80-120 mg per day), then reduce the dose values ??under the control of the ESR.

 

Moya-moya disease

Moya moya, - not studied artery occlusive disease, accompanied by destruction of large intracerebral vessels, especially the internal carotid artery and the trunk of the middle cerebral and anterior cerebral arteries. Lenticular nucleus and the arteries in the striatum form a rich source of collateral blood flow around clogged area subjected to middle cerebral artery, which by angiography of cerebral vessels like a puff of smoke ("moya moya"). Other collaterals include transduralny anastomosis between the superficial cortical branches of middle cerebral artery and arteries of the soft tissues of skull (scalp). This disease occurs mainly among the peoples of the East, but it should be suspected in the development of transient ischemic attack (TIA) or stroke in children and young people.

The etiology of the disease Moya Moya - not known. Several postmortem studies have shown that the narrowing of the lumen of the arteries accompanied by deposition of hyaline fibrous material. Prescribe anticoagulants in patients with neurological symptoms should be especially careful, since it is possible subarachnoid hemorrhage rupture arterial anastomosis transduralnyh. In some cases, recommended operations to create extracranial - intracranial bypass tract, but their effectiveness has not been established. Needed to create a shunt craniotomy can lead to a break transduralnogo anastomoses and theoretically capable of causing an increase of neurological deficit. In addition, extracranial - intracranial bypass surgery may cause blockage (occlusion), proximal (upper) middle cerebral artery area.

 

Oral contraceptives

With the admission of oral contraceptives linked an increased incidence of stroke in young women (13.2 per 100 000 among women taking oral contraceptives compared with 2.8 per 100 000 among those who do not drink). In most cases the patients during angiographic lumen of the proposed arterial is free. If the detected occlusion (blockage of the lumen of the artery), then later a free cross-country in this vessel is restored. This fact can be considered as a major cause of stroke in women taking oral contraceptives, embolism (born with the blood clot). However, the origin of emboli remains unclear. In the postmortem study involved in the arteries and cardiovascular system shows that they are in good condition.

Strokes in young women is also explained by migraine and cigarette smoking, assuming the development of state of increased blood clotting (hypercoagulable state), leading to thrombosis and embolism of cerebral arteries.

 

Polycythemia, thrombotic thrombocytopenic purpura, idiopathic thrombocytosis, albuminosis, sickle cell anemia

Polycythemia, thrombotic thrombocytopenic purpura, idiopathic thrombocytosis, albuminosis and sickle cell anemia can cause patients to ischemic stroke (cerebral infarction). This is due to thrombosis with subsequent arterial embolism, as listed disease accompanied by a heightened state of blood clotting (hypercoagulable state).

 

Binswanger's disease

Binswanger's disease (chronic progressive subcortical encephalopathy) - a rare condition in which heart attacks exposed the subcortical white matter of the brain. Binswanger's disease remain intact U-fibers. Computed tomography (CT) scan of the brain reveal periventricular (around the ventricles of the brain) areas of low absorption of X-rays. In the small arteries of the deep white matter, as it happens and in hypertension invariably evolves lipogialinoz. Binswanger's disease may experience heart attacks in the deep white and gray matter of the brain that corresponds to the zone of the adjacent blood supply to the arteries penetrating the circle of Willis and cerebral cortex. Pathophysiological nature of the disease and even fundamental changes patologoaiatomicheskie remain unclear. The disease - which is one reason abulia and disability in the elderly.

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