Treatment of dyscirculatory encephalopathy

The goal of treatment of chronic cerebral circulatory insufficiency is stabilization, suspension of the destructive process of cerebral ischemia, slowing down the rate of progression, activation of sanogenetic mechanisms of compensation of functions, prevention of both primary and recurrent stroke, therapy of the main background diseases and concomitant somatic processes.

Treatment of acutely developed (or exacerbated) chronic somatic disease is considered mandatory, since against this background, the phenomena of chronic cerebral circulatory failure significantly increase. They, in combination with dysmetabolic and hypoxic encephalopathy, begin to dominate the clinical picture, leading to incorrect diagnosis, non-specialized hospitalization and inadequate treatment.

Indications for hospitalization

Chronic cerebrovascular insufficiency is not considered an indication for hospitalization unless its course is complicated by the development of a stroke or severe somatic pathology. Moreover, hospitalization of patients with cognitive disorders, removing them from their usual environment can only worsen the course of the disease. Treatment of patients with chronic cerebrovascular insufficiency is assigned to the outpatient and polyclinic service; if the cerebrovascular disease has reached stage III of discirculatory encephalopathy, home care is necessary.

Drug treatment of cerebrovascular insufficiency

The choice of medications is determined by the main directions of therapy noted above.

The main directions of basic therapy in the treatment of chronic cerebral circulatory insufficiency are considered to be 2 directions - normalization of brain perfusion by influencing different levels of the cardiovascular system (systemic, regional, microcirculatory) and influence on the platelet link of hemostasis. Both of these directions, while optimizing cerebral blood flow, simultaneously perform a neuroprotective function.

Basic etiopathogenetic therapy, which affects the underlying pathological process, primarily involves adequate treatment of arterial hypertension and atherosclerosis.

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Antihypertensive therapy

Maintaining adequate blood pressure plays a major role in preventing and stabilizing the manifestations of chronic cerebral circulatory insufficiency. The literature contains information on the positive effect of normalizing blood pressure on restoring an adequate response of the vascular wall to the gas composition of the blood, hyper- and hypocapnia (metabolic regulation of blood vessels), which affects the optimization of cerebral blood flow. Maintaining blood pressure at 150-140/80 mm Hg prevents the development of mental and motor disorders in patients with chronic cerebral circulatory insufficiency. In recent years, it has been shown that antihypertensive drugs have a neuroprotective property, that is, they protect surviving neurons from secondary degenerative damage after a stroke and/or chronic cerebral ischemia. In addition, adequate antihypertensive therapy helps prevent the development of primary and recurrent acute cerebrovascular accidents, the background for which is often chronic cerebrovascular insufficiency.

It is very important to start hypotensive therapy early, before the development of a pronounced "lacunar state" that determines the disconnection of cerebral structures and the development of the main neurological syndromes of discirculatory encephalopathy. When prescribing hypotensive therapy, sharp fluctuations in blood pressure should be avoided, since with the development of chronic cerebral circulatory insufficiency, the mechanisms of autoregulation of cerebral blood flow are reduced, which will already depend to a greater extent on systemic hemodynamics. In this case, the autoregulation curve will shift towards higher systolic blood pressure, and arterial hypotension (<110 mm Hg) will adversely affect cerebral blood flow. In this regard, the prescribed drug should adequately control systemic pressure.

Currently, a large number of antihypertensive drugs from different pharmacological groups have been developed and introduced into clinical practice, allowing to ensure control of arterial pressure. However, the obtained data on the important role of the renin-angiotensin-aldosterone system in the development of cardiovascular diseases, as well as on the relationship between the content of angiotensin II in the central nervous system and the volume of ischemia of the cerebral tissue, allow today in the treatment of arterial hypertension in patients with cerebrovascular pathology to give preference to drugs that affect the renin-angiotensin-aldosterone system. These include 2 pharmacological groups - inhibitors of angiotensin-converting enzyme and antagonists of angiotensin II receptors.

Both angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists have not only an antihypertensive effect, but also an organoprotective effect, protecting all target organs affected by arterial hypertension, including the brain. The PROGRESS (appointment of the angiotensin-converting enzyme inhibitor perindopril), MOSES and OSCAR (use of the angiotensin II receptor antagonist eprosartan) studies have proven the cerebroprotective role of antihypertensive therapy. The improvement of cognitive functions against the background of taking these drugs should be especially emphasized, given that cognitive disorders to one degree or another are present in all patients with chronic cerebrovascular insufficiency and are the dominant and most dramatic disabling factors in severe stages of cerebrovascular insufficiency.

According to the literature, the influence of angiotensin II receptor antagonists on degenerative processes occurring in the brain, in particular, in Alzheimer's disease, cannot be ruled out, which significantly expands the neuroprotective role of these drugs. It is known that recently most types of dementia, especially in old age, are considered as combined vascular-degenerative cognitive disorders. It should also be noted the supposed antidepressant effect of angiotensin II receptor antagonists, which is of great importance in the treatment of patients with chronic cerebral circulatory insufficiency, who often develop affective disorders.

In addition, it is very important that angiotensin-converting enzyme inhibitors are indicated for patients with signs of heart failure, nephritic complications of diabetes mellitus, and angiotensin II receptor antagonists are capable of exerting angioprotective, cardioprotective, and renoprotective effects.

The antihypertensive efficacy of the indicated groups of drugs increases when combined with other antihypertensive agents, most often with diuretics (hydrochlorothiazide, indapamide). The addition of diuretics is especially indicated in the treatment of elderly women.

Hypolipidemic therapy (treatment of atherosclerosis)

In addition to a diet with limited animal fats and predominant use of vegetable fats, it is advisable to prescribe hypolipidemic agents, in particular statins (atorvastatin, simvastatin, etc.), which have a therapeutic and prophylactic effect, to patients with atherosclerotic cerebral vascular lesions and dyslipidemia. These drugs are more effective in the early stages of cerebrovascular insufficiency. They have been shown to be able to reduce cholesterol levels, improve endothelial function, reduce blood viscosity, stop the progression of the atherosclerotic process in the main arteries of the head and coronary vessels of the heart, have an antioxidant effect, and slow down the accumulation of beta-amyloid in the brain.

Antiplatelet therapy

It is known that ischemic disorders are accompanied by activation of the platelet-vascular link of hemostasis, which determines the mandatory prescription of antiplatelet drugs in the treatment of chronic cerebral circulatory insufficiency. Currently, the effectiveness of acetylsalicylic acid has been most thoroughly studied and proven. Enteric-soluble forms are mainly used at a dose of 75-100 mg (1 mg / kg) daily. If necessary, other antiplatelet agents (dipyridamole, clopidogrel, ticlopidine) are added to the treatment. The prescription of drugs in this group also has a preventive effect: it reduces the risk of myocardial infarction, ischemic stroke, peripheral vascular thrombosis by 20-25%.

A number of studies have shown that basic therapy (antihypertensive, antiplatelet) alone is not always sufficient to prevent the progression of vascular encephalopathy. In this regard, in addition to the constant intake of the above groups of drugs, patients are prescribed a course of treatment with agents that have antioxidant, metabolic, nootropic, and vasoactive effects.

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Antioxidant therapy

As chronic cerebral circulatory failure progresses, there is an increasing decrease in protective sanogenetic mechanisms, including the antioxidant properties of plasma. In this regard, the use of antioxidants such as vitamin E, ascorbic acid, ethylmethylhydroxypyridine succinate, and actovegin is considered pathogenetically justified. Ethylmethylhydroxypyridine succinate (mexidol) can be used in tablet form for chronic cerebral ischemia. The initial dose is 125 mg (one tablet) 2 times a day with a gradual increase in the dose to 5-10 mg/kg per day (maximum daily dose is 600-800 mg). The drug is used for 4-6 weeks, the dose is gradually reduced over 2-3 days.

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Use of combination drugs

Considering the diversity of pathogenetic mechanisms underlying chronic cerebral circulatory insufficiency, in addition to the above-mentioned basic therapy, patients are prescribed drugs that normalize the rheological properties of blood, microcirculation, venous outflow, and have antioxidant, angioprotective, neuroprotective, and neurotrophic effects. To exclude polypharmacy, preference is given to drugs that have a combined effect, a balanced combination of medicinal substances in which eliminates the possibility of drug incompatibility. Currently, a fairly large number of such drugs have been developed.

Below are the most common drugs with a combined effect, their doses and frequency of use:

• ginkgo biloba leaf extract (40-80 mg 3 times a day);
• vinpocetine (5-10 mg 3 times a day);
• dihydroergocryptine + caffeine (4 mg 2 times a day);
• hexobendine + etamivan + etofillin (1 tablet contains 20 mg hexobendine, 50 mg etamivan, 60 mg etofillin) or 1 forte tablet, which contains 2 times more of the first 2 drugs (taken 3 times a day);
• piracetam + cinnarizine (400 mg niracetam and 25 mg cinnarizine, 1-2 capsules 3 times a day);
• vinpocetine + piracetam (5 mg vinpocetine and 400 mg piracetam, one capsule 3 times a day);
• pentoxifylline (100 mg 3 times a day or 400 mg 1 to 3 times a day);
• trimethylhydrazinium propionate (500-1000 mg once a day);
• nicergoline (5-10 mg 3 times a day).

The indicated drugs are prescribed in courses of 2-3 months 2 times a year, alternating them for individual selection.

The effectiveness of most drugs that affect blood flow and metabolism of the brain is demonstrated in patients with early, i.e. with stages I and II of cerebrovascular insufficiency. Their use in more severe stages of chronic cerebral circulatory failure (in stage III of cerebrovascular insufficiency) can give a positive effect, but it is much weaker.

Despite the fact that they all have the above-described set of properties, one can dwell on some selectivity of their action, which may be important in choosing a drug taking into account the identified clinical manifestations.

• Ginkgo biloba leaf extract accelerates vestibular compensation processes, improves short-term memory, spatial orientation, eliminates behavioral disorders, and also has a moderate antidepressant effect.
• Dihydroergocryptine + caffeine acts primarily at the level of microcirculation, improving blood flow, tissue trophism and their resistance to hypoxia and ischemia. The drug helps improve vision, hearing, normalize peripheral (arterial and venous) blood circulation, reduce dizziness, tinnitus.
• Hexobendine + etamivan + etofylline improves concentration, integrative brain activity, normalizes psychomotor and cognitive functions, including memory, thinking and performance. It is advisable to slowly increase the dose of this drug, especially in elderly patients: treatment begins with 1/2 tablet per day, increasing the dose by 1/2 tablet every 2 days, bringing it to 1 tablet 3 times a day. The drug is contraindicated in epileptic syndrome and increased intracranial pressure.

Metabolic therapy

Currently, there are a large number of drugs that can affect neuronal metabolism. These are drugs of both animal and chemical origin that have a neurotrophic effect, chemical analogues of endogenous biologically active substances, agents that affect cerebral neurotransmitter systems, nootropics, etc.

Neurotrophic action is provided by such drugs as Cerebrolysin and polypeptides of the cerebral cortex of cattle (polypeptide cocktails of animal origin). It is necessary to take into account that in order to improve memory and attention, patients with cognitive disorders caused by vascular cerebral pathology should be administered fairly large doses:

• Cerebrolysin - 10-30 ml intravenously by drip, per course - 20-30 infusions;
• polypeptides of the cerebral cortex of cattle (cortexin) - 10 mg intramuscularly, per course - 10-30 injections.

Domestic drugs glycine and semax are chemical analogues of endogenous biologically active substances. In addition to their main effect (improved metabolism), glycine can produce a mild sedative effect, and semax - an exciting effect, which should be taken into account when choosing a drug for a particular patient. Glycine is a replaceable amino acid that affects the glutamatergic system. The drug is prescribed in a dose of 200 mg (2 tablets) 3 times a day, the course is 2-3 months. Semax is a synthetic analogue of adrenocorticotropic hormone, its 0.1% solution is administered 2-3 drops in each nasal passage 3 times a day, the course is 1-2 weeks.

The term "nootropics" unites various drugs capable of improving the integrative activity of the brain, having a positive effect on memory and learning processes. Piracetam, one of the main representatives of this group, has the noted effects only when prescribed in large doses (12-36 g / day). It should be borne in mind that the use of such doses by elderly people can be accompanied by psychomotor agitation, irritability, sleep disturbance, and also provoke an exacerbation of coronary insufficiency and the development of epileptic paroxysm.

Symptomatic treatment of cerebrovascular insufficiency

In the development of vascular or mixed dementia syndrome, background therapy is enhanced with agents that affect the exchange of the main neurotransmitter systems of the brain (cholinergic, glutamatergic, dopaminergic). Cholinesterase inhibitors are used - galantamine at 8-24 mg / day, rivastigmine at 6-12 mg / day, modulators of glutamate NMDA receptors (memantine at 10-30 mg / day), agonist D2 / D3 dopamine receptors with a2-noradrenergic activity piribedil at 50-100 mg / day. The last of the indicated drugs is more effective in the early stages of discirculatory encephalopathy. It is important that along with improving cognitive functions, all the above-mentioned drugs are able to slow down the development of affective disorders that may be resistant to traditional antidepressants, as well as reduce the severity of behavioral disorders. To achieve the effect, the drugs should be taken for at least 3 months. These drugs can be combined, replaced by one another. If the result is positive, it is recommended to take an effective drug or drugs for a long time.

Dizziness significantly worsens the quality of life of patients. Such of the above-mentioned drugs as vinpocetine, dihydroergocryptine + caffeine, ginkgo biloba leaf extract can eliminate or reduce the severity of vertigo. If they are ineffective, otoneurologists recommend taking betahistine 8-16 mg 3 times a day for 2 weeks. The drug, along with reducing the duration and intensity of dizziness, weakens the severity of vegetative disorders and noise, and also improves coordination of movement and balance.

Special treatment may be required if patients develop affective disorders (neurotic, anxious, depressive). In such situations, antidepressants that do not have an anticholinergic effect (amitriptyline and its analogues) are used, as well as intermittent courses of sedatives or small doses of benzodiazepines.

It should be noted that the division of treatment into groups according to the main pathogenetic mechanism of the drug is very conditional. For a broader acquaintance with a specific pharmacological agent, there are specialized reference books, the purpose of this guide is to determine the directions in treatment.

Surgical treatment of cerebrovascular insufficiency

In case of occlusive-stenotic lesion of the main arteries of the head, it is advisable to raise the question of surgical elimination of the vascular patency obstruction. Reconstructive operations are most often performed on the internal carotid arteries. This is carotid endarterectomy, carotid artery agency. The indication for their implementation is the presence of hemodynamically significant stenosis (overlapping more than 70% of the vessel diameter) or a loose atherosclerotic plaque, from which microthrombi can break away, causing thromboembolism of small cerebral vessels.

Approximate periods of incapacity for work

The disability of patients depends on the stage of cerebrovascular insufficiency.

• At stage I, patients are able to work. If temporary disability occurs, it is usually due to intercurrent diseases.
• Stage II of discirculatory encephalopathy corresponds to II-III disability groups. However, many patients continue to work, their temporary disability can be caused by both a concomitant disease and an increase in the symptoms of chronic cerebral circulatory insufficiency (the process often occurs in stages).
• Patients with stage III cerebrovascular insufficiency are unable to work (this stage corresponds to disability groups I-II).

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Further management

Patients with chronic cerebral circulatory failure require constant background therapy. The basis of this treatment is the means of correcting arterial pressure and antiplatelet drugs. If necessary, substances are prescribed that eliminate other risk factors for the development and progression of chronic cerebral ischemia.

Non-drug methods of influence are also of great importance. They include adequate intellectual and physical exercise, feasible participation in social life. In frontal dysbasia with disorders of gait initiation, freezing, and the threat of falls, special gymnastics is effective. Stabilometric training based on the principle of biological feedback helps to reduce ataxia, dizziness, and postural instability. Rational psychotherapy is used for affective disorders.

Information for patients

Patients must follow the doctor's recommendations for both regular and course medication intake, monitor blood pressure and body weight, quit smoking, follow a low-calorie diet, and eat foods rich in vitamins.

It is necessary to carry out health-improving gymnastics, use special gymnastic exercises aimed at maintaining the functions of the musculoskeletal system (spine, joints), and take walks.

It is recommended to use compensatory techniques to eliminate memory disorders, write down necessary information, and make a daily plan. It is necessary to maintain intellectual activity (reading, memorizing poems, talking on the phone with friends and family, watching TV, listening to music or interesting radio programs).

It is necessary to perform feasible household chores, try to lead an independent lifestyle for as long as possible, maintain physical activity while taking precautions to avoid falling, and use additional support devices if necessary.

It should be remembered that in elderly people after a fall, the degree of severity of cognitive disorders increases significantly, reaching the severity of dementia. To prevent falls, it is necessary to eliminate the risk factors for their occurrence:

• remove carpets that the patient might trip over;
• wear comfortable, non-slip shoes;
• if necessary, rearrange the furniture;
• attach handrails and special handles, especially in the toilet and bathroom;
• The shower should be taken in a sitting position.

Forecast

The prognosis depends on the stage of discirculatory encephalopathy. The same stages can be used to assess the rate of disease progression and the effectiveness of treatment. The main unfavorable factors are severe cognitive disorders, often occurring in parallel with an increase in episodes of falls and the risk of injury, such as craniocerebral trauma and fractures of the extremities (primarily the femoral neck), which create additional medical and social problems.

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