Volume 03 Issue 04-2023
116
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
04
P
AGES
:
116-120
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
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Servi
ABSTRACT
This article discusses the state of cerebral hemodynamics in patients with lacunar stroke. To evaluate and compare
the state of cerebral hemodynamics in patients with lacunar stroke and hemorrhagic stroke of the brain. Therefore,
conducting a detailed study on the diagnosis and treatment of lacunar cerebral infarction against the background of
arterial hypertension, taking into account its subtypes, remains extremely relevant and has not yet been solved.
KEYWORDS
Cerebral hemodynamics, lacunar stroke, hemorrhagic stroke, cerebral infarction, arterial hypertension.
INTRODUCTION
Circulatory disorders of the brain are the second most
important cause of mortality in the structure of general
mortality of the population, second only to
cardiovascular pathology. In this regard, interest in the
issues of cerebral blood flow disorders does not
weaken all over the world, more and more new aspects
of this problem are being considered. Acute
cerebrovascular accidents against the background of
arterial hypertension deserve special attention. It is
known that hypertension equally implements both
extensive hemorrhagic strokes and lacunar cerebral
infarctions (1,2,34).
Lacunar infarction (LI) of the brain, caused by damage
to the perforating arteries, is usually localized in the
deep structures of the brain. The affected area does
not exceed 15-20 mm in diameter. The frequency of LI,
according to various authors, ranges from 13% to 37%
(on average, about 20%) of cerebral infarctions. The
death rate in patients with LI is 9.8%, and recurrent
ischemic strokes (IS) develop in 11.8% of patients during
the first year. The dynamics of brain LI disease in
patients, in most cases, proceeds with satisfactory
regression. According to the data of foreign authors,
65-68% of patients did not need outside care a year
after the brain LI. However, the risk of developing
Research Article
STATE OF CEREBRAL HEMODYNAMICS IN PATIENTS WITH LACUNAR
STROKE
Submission Date:
April 20, 2023,
Accepted Date:
April 25, 2023,
Published Date:
April 30, 2023
Crossref doi:
https://doi.org/10.37547/ijmscr/Volume03Issue04-18
R.Sh. Abdurakhmanov
Center For The Development Of Professional Qualifications Of Medical Workers, Uzbekistan
Journal
Website:
https://theusajournals.
com/index.php/ijmscr
Copyright:
Original
content from this work
may be used under the
terms of the creative
commons
attributes
4.0 licence.
Volume 03 Issue 04-2023
117
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
04
P
AGES
:
116-120
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
repeated
acute
cerebrovascular
accidents
is
significantly higher in patients with a history of
cardiovascular diseases (4,56).
According to various literary sources, during the first
year after a brain LI, repeated LI develops in 25-30% of
b-x, and over the next 3 years in another 18-20% of b-x
(D. Benninger 2004).
Therefore, conducting a detailed study on the
diagnosis and treatment of lacunar cerebral infarction
against the background of arterial hypertension, taking
into account its subtypes, remains extremely relevant
and has not yet been solved.
Purpose of the study. To evaluate and compare the
state of cerebral hemodynamics in patients with
lacunar stroke and hemorrhagic stroke of the brain.
Research material. We observed 180 patients with
stroke, including 80 (66.7%) patients with lacunar
cerebral infarction and 40 (33.3%) patients with
hemorrhagic stroke. Diagnosis was carried out in
accordance with ICD-
10 and “Classification of vascular
lesions of the brain and spinal cord” (Schmidt E.V.,
Dubovskaya N.G., Sokolov A.B., 2002). All 120 patients
were in the Department of Emergency Neurology of
the RRCEMMP. The age of the patients ranged from 35
to 86 years, on average 61.9±1.3 years. There were 65
men (54.2%), 55 women (45.8%).
Research methods. The following research methods
were used in the work: Clinical questionnaire, Clinical
neurological examination, Ambulatory blood pressure
monitoring (ABPM), Ultrasound MAG and TCDG BCV.
Statistical processing and visualization of the obtained
results were carried out using the software package
for statistical analysis STATISTICA v. 10 and built-in
functions of Microsoft Office Excel. When conducting
statistical analysis, the critical level of significance of
the null statistical hypothesis was taken equal to 0.05.
Research results. The state of blood circulation was
assessed according to the results of ultrasound and
TCDG BCV. Regardless of the type of stroke and age,
the carotid pool was the most common site of stroke
67 (83.75±6.1%) cases.
Vertebrobasilar stroke was registered in 13 (16.25±4.7%)
patients, while the differences between the groups
(brain LI and GI) did not reach a statistically significant
level. According to TCDG and duplex scanning,
atherosclerotic changes in the arteries of 76 (95.0%)
were most common in patients with brain LI, and
hemodynamically significant stenoses were found in 12
(15.0±2.2%) patients with combined foci.
The identified atherosclerotic changes in patients were
localized both in the carotid and vertebrobasilar
basins, which indicated a diffuse prevalence of the
pathological process. However, not in all cases, the foci
detected on CT were located in the corresponding
vascular pool, which confirms the opinion about a
systemic disorder of cerebral circulation in lacunar
stroke.
Table 1.
The state of the BCS vessels and its relationship with A/D in brain LI and GI.
Volume 03 Issue 04-2023
118
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
04
P
AGES
:
116-120
SJIF
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(2021:
5.
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(2022:
5.
893
)
(2023:
6.
184
)
OCLC
–
1121105677
Publisher:
Oscar Publishing Services
Servi
Indicators
LI=80
GI=40
Stenosis of the BCS
Unilateral stenosis over 50%
12 (15,0±2,2%)*
4 (10,0±4,7%)
Bilateral massive stenosis over 50%
34 (42,5±5,5%)*
10 (25,0±6,8%)
Average A/D in the acute period of stroke
Systol. (Hg)
161
210*
diastole (Hg)
90
105
As can be seen from this table 1, in patients with brain
LI, unilateral stenosis of the intracranial parts of the ICA
was statistically significantly more common; more than
50% was recorded in 12 (15.0±2.2%) patients with brain
LI, and 4 (10 0±4.7%). Bilateral massive stenosis with LI
of the brain more than 50% was determined in 34
(42.5±5.5%) cases, and with GI only in 10 (25.0±6.8%)
cases. This indicates that LI most often developed with
massive stenoses of two or more BCS vessels.
At the same time, the comparison of the mean A/D in
both groups at the time of stroke was significantly
higher in patients who had a GI of 210/105 mm Hg,
despite the lower proportion of stenotic lesions of the
BCS vessels, versus 161/90 mm Hg. Art in patients
undergoing LI.
Thus, LI of the brain can develop with massive bilateral
stenosis of two or more BCS vessels, even with
relatively low A/D values.
Tab. 2. Duplex scanning of brachiocephalic arteries in patients with GI
Vessel
Diameter
(mm)
Norm
(mm)
VPS
(sm/s)
Norm
(mm)
RI
Norm
P
L
P
L
P
L
CCA
5,5
5,1
4,7-9,7 76,4 78,9 50-124 0,78 0,73 0,65-0,75
ECА
3,7
3,7
2,8-6,0 81,3 82,0 45-136 0,64 0,66 0,70-0,78
ВСА 3,1
2,7
3,3-7,2 66,4 62,7 36-115 0,44 0,45 0,50-0,65
VA
2,1
2,8
2,2-4,5 36,4 40,1
30-71
0,50 0,52 0,52-0,65
IMT
0,08-0,09 mm.
0.07-0.09
As can be seen from Table 2, according to duplex
scanning of the BCS in the b-x group with HI, a
tendency to a decrease in LBF at rest and RI with a
slight asymmetry of cerebral blood flow was more
often recorded. At the same time, the patency of the
vessels remained preserved, but the geometry of the
vessels was changed. Most often, an indirect course
was noted in the vertebral arteries. At the same time,
the intima-media complex (IMC) remained within the
normal range of 0.08-0.09 cm. Further clinical and
paraclinical studies in both groups showed that in
patients who underwent LI, there is stenosis of the
Volume 03 Issue 04-2023
119
International Journal of Medical Sciences And Clinical Research
(ISSN
–
2771-2265)
VOLUME
03
ISSUE
04
P
AGES
:
116-120
SJIF
I
MPACT
FACTOR
(2021:
5.
694
)
(2022:
5.
893
)
(2023:
6.
184
)
OCLC
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1121105677
Publisher:
Oscar Publishing Services
Servi
intracranial arteries of the brachycephalic system
(BCS), which is reflected in Table 3.
As can be seen from Table 3, the speed indicators of
blood flow in the CCA on the right were significantly
lower 36.0 cm/sec than on the left 43.8 cm/sec
(normally 50-124 cm/sec). It is interesting that this
particular indicator for NSA in the group of b-x with LI
of the brain, on both sides, remained within the normal
range. This indicates less involvement of extracranial
vessels in the pathological process. The presence of a
symmetrical and asymmetric main flow type and signs
of difficult perfusion against the background of
hyalinosis and arteriolosclerosis of perforating vessels
was observed mainly in patients with small cortical and
lacunar strokes with a mild course and good recovery
of neurological functions. It is also important that, in
the majority of b-x with multiple foci of brain LI on DS
BCCJ, echographic signs of stenosing atherosclerosis in
the carotid arteries were noted. Many of them
revealed hyperechoic ASP in CCA, ICA with lumen
stenosis up to 50-55%. Deformation of the ICA and VA
was noted. The intima-media complex thickened up to
1.2-2.4 mm, which is reflected in Table No. 23.
Thus, USDG MAG in the group of bx with LI of the brain
made it possible to reveal quite noticeable changes. In
the vast majority of b-x with brain LI on the BCS, the
patency on both sides was impaired, deviation and
deformation of the course of the arteries supplying the
brain, which together ultimately led to the formation
of a significant deficit in cerebral blood flow.
Table 3. Duplex scanning of brachiocephalic arteries in patients with LI of the brain.
Vessel Diameter
(mm)
Norm
(mm)
VPS
(cm/s)
Norm
(cm/sec)
RI
Norm
P
L
P
L
P
L
CCA
7,8
7,4 4,7-9,7 36,0 43,8 50-124 0,78 0,71 0,65-0,75
ECА
3,5
4,0 2,8-6,0 53,2 67,7 45-136 0,46 0,44 0,70-0,78
ВСА 4,9 4,8 3,3-7,2 42,0 59,3 36-115 0,64 0,62 0,50-0,65
VA
3,7
3,4 2,2-4,5 21,5 37,7
30-71
0,63 0,57 0,52-0,65
IMT
1,2-2,4 mm.
0.07-0.09
In patients with GI, according to the MAG ultrasound,
there were cases of non-closed circle of Willis. In our
opinion, such an abnormal development of the vessels
of the base of the brain against the background of a
crisis course of the arterial can serve as a hydrodynamic
shock and the appearance of microanaurisms. This is
especially true if the patient has a history of diabetes
mellitus. The obtained results of a comparison
between the two selected types of impaired cerebral
hemodynamics, with the results of examination on a
computed tomography and the etiological causes of
both LI and GI, made it possible to give a pathogenetic
characteristic of each of the identified patterns. The
proposed approach can be used to predict various
forms of stroke.
CONCLUSION
The results of our studies have established that the
MAG ultrasound parameters of blood flow at rest in GI
and LI of the brain, as a rule, are accompanied by
Volume 03 Issue 04-2023
120
International Journal of Medical Sciences And Clinical Research
(ISSN
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2771-2265)
VOLUME
03
ISSUE
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P
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:
116-120
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Publisher:
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certain changes, which are expressed by a
predominant violation of blood filling in the ICA basin,
which indicates the prevailing involvement of the
region of intracranial blood supply in the pathological
process. When LI of the brain develops against the
background of AH, there are tendencies to a moderate
symmetrical decrease in mean LBF, stenosing
atherosclerosis, an increase in peripheral vascular
resistance, deviation and deformation of the course of
blood vessels, which may reflect their hypertensive
angiopathy of intracranial perforant arteries and serve
as a background for the development of LI of the brain.
And here, too, it should be noted that the higher the
level of digital indicators of hypertension, the faster
and deeper structural changes in the vascular system
develop.
In our opinion, timely differential diagnosis, based on a
comparison of neuroimaging parameters and USDG
MAH changes, is of great clinical importance for
determining the prognosis, the features of the further
clinical course and the selection of adequate
therapeutic therapy. And effective and adequate
treatment aimed at the prevention of hypertension
opens up great opportunities for preventing the risk of
developing and reducing the incidence of brain LI and
preventing possible major strokes. They significantly
increase the diagnostic and prognostic capabilities of
Doppler ultrasound. And at the same time, it should be
noted that, in patients who have undergone LI,
repeated cerebrovascular accidents are only lacunar in
nature and are much more common than repeated IS
or GI. And this can be seen on a large number of
materials of CT studies, where multiple hypodense foci
of various sizes were found in the subcortical and
periventricular zones. This indicates that, if it
originated in the brain, then there are quite serious
irreversible changes in the vascular system of the brain,
which are the reason for the more frequent recurrence
of this form of stroke.
If our assumption is correct, then our conclusions make
it possible to single out, guided by the obtained data of
BCS ultrasound and duplex scanning among patients
with hypertension, a risk group for the development of
brain LI, even in the absence of a neurological deficit
clinic.
REFERENCES
1.
Gusev E.I., Skvortsova V.I. cerebral ischemia.
Moscow: Medicine; 2001.
2.
Stroke. Guide for doctors. Ed. Stakhovskoy
L.V., Kotova S.V. Publishing house MIA; 2013.
3.
Hennerici M.G., Boguslavsky J., Sakko R.L.
Stroke. Clinical guide. Per. from English. Under
the general editorship. corresponding member
RAMS Skvortsova V.I. 2nd ed. Moscow:
MEDpress-info; 2008.
4.
Prevention
and
treatment
of
venous
thromboembolism. International Consensus
Statement (Guidelines according to scientific
evidence). Under the auspices of the
Cardiovascular
Disease
Educational
and
Research Trust, European Venous Forum,
North
American
Thrombosis
Forum,
International Union of Angiology and Union
Internationale du Phlebologic
—
2013.
5.
Tissue Plasminogen Activator For Acute
lshemic Stroke. The New England Journal Of
Medicine. 1995;333:24.
6.
Wolf PA, Abbott RD, Kanncl W. B. Atrial
fibrillation as an independent risk factor for
stroke: the Framingham Study. Stroke.
1991;22:983-988.
