How is chronic cerebral ischemia diagnosed? Take a look at the latest expert consensus

Attaching importance to and effectively preventing and treating chronic cerebral ischemia (CCH) is an effective program

definition

Chronic cerebral ischemia, also known as chronic cerebral hypoperfusion, refers to structural lesions of cerebrovascular diseases and (or) abnormal hypoperfusion of blood concentration and hemomobility caused by a variety of reasons, resulting in a decrease in the overall level of the brain or the regional blood supply of anterior and posterior circulation, rather than focal cerebral ischemia, cerebral blood flow is lower than the physiological demand of brain tissue, and is in a decompensated state [decompensated state refers to cerebral blood flow less than 25 ~ 45mL / (100g · min), can not maintain normal brain tissue metabolism needs, causing a series of chronic, Fluctuating cerebral dysfunction syndrome, and clinical disease syndrome without clear signs of focal systemic nerve loss, excluding TIA, cerebral infarction, acute vascular dementia, etc.

pathogen

Decreased cerebral blood supply is a starting factor for chronic cerebral ischemia for a variety of reasons, including:

➤ Vascular factors: large and middle atherosclerosis, abnormal compression of blood vessels by cervical flexion, abnormal vascular development, etc.

➤ Hemodynamic disorders: such as cardiogenic, orthopatic,

➤ Small vascular lesions: refers to a group of diseases involving microarteries, capillaries and microveins, accounting for 25% of cerebrovascular disease, the lesions are relatively wide, will have a certain impact on the brain, long-term microvascular lesions lead to narrowing of the lumen, occlusion, clinical medical imaging can see cerebral leukogenesis and asymptomatic multiple cavity infarction

➤ Other factors: such as abnormal blood components: erythrocytopenia, thrombotic thrombocytopenia, eosinophilia, etc.

Clinical manifestations

The onset of this disease is insidious, the clinical symptoms are not specific, according to the current clinical data, its main clinical manifestations can be summarized as:

(1) General non-specific headache and facial paresthesias such as dull pain, swelling pain or tightening discomfort of the whole head, dizziness or dizziness all day, no sense of

(2) Sleep disorders, including difficulty falling asleep, waking up early, difficulty falling asleep after waking up, mental fatigue during the day, worse spirit after meals, sleepiness, weakness and fatigue, etc

(3) Memory impairment dominated by recent memory decline, lack of concentration, slow thinking response, lack of interest in new things, difficulty learning and accepting new things and information, difficulty in forgetting, temporary recall of people or things that have long been familiar with daily life, and even inability to communicate normally

(4) Mental and psychological abnormalities
such as irritability, mood fluctuations, mood, depression, worry, silence, loneliness, laziness, indifference and desirelessness.

(5) Others, such as tinnitus, dizziness, hearing loss, brain ringing, occasional single or double limbs numbness, weakness, stiffness, and landing on the ground; Physical symptoms
such as walking instability, salivation, facial numbness, tongue numbness, lip numbness, drinking water cough, temporary blindness, decreased urinary control, fainting, and sweating, palpitations.

(6) There are no clear signs of localization damage on neurological examination, and there may be hypertendon reflexes, positive palmomandibular reflexes and sucking reflexes
.

Imaging presentation

In the diagnosis of CCH, the clinical manifestations are often non-specific, imaging is an important basis, and when the equipment is gradually popularized, the examination should be carried out as much as possible, such as the following manifestations to help the diagnosis:

(1) Color ultrasound examination has abnormal changes
such as cerebral atherosclerosis, multiple plaque formation, arterial stenosis or occlusion.

(2) Whether there is a clear corresponding sign of lacunar cerebral infarction and/or mild, scattered leukogenesis, single or combined abnormalities
on head CT and/or MRI examination.

The DWI/ADC is mostly abnormal
.

(3) DSA, CTA or MRA examination may have abnormal development, stenosis and occlusion of cerebral perfusion arteries with relatively intact compensation, and some patients may see collateral angiogenesis
.

(4) Positron emission computed tomography (PET), single-photon emission computed tomography (SPECT), computed tomography (CTP), magnetic resonance perfusion imaging (PWI) and other brain functional imaging examinations confirm that there are multiple areas of cerebral blood flow reduction, of which CTP is the simplest and fastest
.

(5) Spectroscopy detection can see a decrease in NAA and an increase in Cho, a decrease in NAA/Cho in the lesion area, and a small number of patients can see Lac peak, which can be used as a reference index
for the degree of brain tissue damage.

Diagnostic criteria

Articles 2, 3 and 5 of the following standards are prerequisites; Those with 1, 4, 7, and 8 can be clinically likely, and if they have any 1 of the 6 items, they can be clinically confirmed
.

(1) More common in the middle and elderly, the age is in principle more than 60 years old, because the symptoms of the disease are easy to superimpose with somatization disorders (neurosis, menopausal syndrome) and other symptoms around the age of 45, sometimes it is difficult to distinguish clearly
.

Considering that cerebral arteriosclerosis, cerebral arteritis, etc.
are supported by the trend of rejuvenation and circulation data, it can be relaxed to over 45 years old, and the diagnosis can be comprehensively judged
.

(2) There is circumstantial evidence of risk factors for cerebrovascular disease and structural vascular lesions and chronic hemodynamic disorders such as cerebral arteriosclerosis, such as hypertension, diabetes, and dyslipidemia (risk factors); History of chronic heart failure or prolonged hypotension (cerebral hypoperfusion); or sclerosis of coronary heart disease or peripheral arteries (ophthalmic, temporal, radial, etc.
); Vascular murmurs (arteriosclerosis or vascular stenosis circumstantial evidence)
may be heard.

(3) There are symptoms of chronic and persistent dizziness, dizziness, bloating pain, memory loss (obvious in close memory), slow response, inattention, emotional instability, decreased ability to work, sleep disorders, walking instability, prolongation, swallowing disorders and other symptoms, these symptoms are the subjective feelings of patients, the degree is mild (does not affect work) or mild to moderate (conscious symptoms are heavy, work efficiency is low), symptoms are fluctuating, sometimes light and heavy
.

(4) The onset is insidious, the course of the disease is long, the ≥ 3 months, and the symptoms are fluctuating and chronic progression
.

(5) There are no positive signs of focal nerve damage in the brain, and there may be active tendon reflexes that are not systematically localized, palmomandibular reflexes, sucking reflexes, and positive Rosorimo signs
.

In particular, it is necessary to exclude positive signs of TIA and cerebral infarction
.

(6) There is radiographic supporting evidence
.

(7) The use of cerebral circulation improvers and brain metabolites has the effect of
improving symptoms.

(8) Accurately exclude other related diseases that can cause the above symptoms, such as inner ear vertigo, somatization disorders, anxiety and depression, subjective dizziness and related accompanying symptoms of various degenerative diseases
.

Clinical typing

Although CCH has a holistic ischemic basis, it is mainly based on regional cerebral blood flow reduction and patients have different clinical symptoms, so from a clinical practical point of view, it can be classified as follows
.

➤ Divided by ischemic site

➤ Chronic posterior circulation (vertebraebrobasil) ischemic type: this type is the most common, the most reported in the literature, the risk is large, once it develops into acute infarction, the disability fatality rate is high, and the diagnostic criteria are: (1) in line with the diagnostic basis
of chronic cerebral ischemia.

(2) Persistent vertebraebrobasilar artery insufficiency of blood supply: mainly dizziness, agitation, walking instability, tilting, standing unsteadiness or light-headedness, generally not accompanied by nausea; Severe symptoms may present with brief dizziness, with mild nausea, blurred vision, and limb weakness
.

These symptoms may fluctuate, be mild and severe, worsen dizziness when position changes or when walking is longer, and lessen or disappear
in the lying position.

(3) There are or are no signs of mild localization damage of the nervous system, such as active tendon reflex, bilateral Rosorimo sign (+), closed eyes standing sign (±), etc
.

(4) MRI shows that there may be asymptomatic lacunar cerebral infarction, mild cerebellar atrophy, and mild enlargement of the quadriple ventricles
.

MRA or CTA may show vertebrae-basilar atherosclerosis, irregular stenosis, developmental abnormalities, prolonged dilation, etc
.

➤ Chronic anterior circulation (internal carotid artery) ischemic type: (1) Consistent with the diagnosis of
chronic cerebral ischemia.

(2) The main manifestations are forebrain dysfunction, that is, psychoneurological symptoms: memory loss, especially recent event forgetting, name forgetting, etc.
, slow response, indifferent expression, lack of concentration, emotional instability (anxiety, irritability), insomnia, decreased work ability, decreased judgment, and even personality changes, paranoia, mild dementia, hemian limb tingling, acid sleepiness, chills, etc
.
over time.

(3) There are no definite signs of systemic nerve localization damage, but there may be positive sucking reflex, positive palmomandibular reflex, Rosorimo sign (+), active tendon reflex, etc
.

(4) Imaging without or with cerebral hemisphere "asymptomatic cavity infarction", mild cerebral atrophy and different degrees of white matter demyelination
.

MRA or CTA examination, common carotid artery, internal carotid artery system may have vascular stenosis, atherosclerosis, internal carotid myofibrous dysplasia, Moyamoya disease, etc.
; The intraparenchymal artery vascular branches are reduced, but the collateral branches of the blood vessel are generally well formed, and the symptoms are not commensurate
with the images.

The chronic total ischemic group meets the diagnostic criteria of CCH and has symptoms, signs, and imaging manifestations
of anterior and posterior circulating hyposupply.

➤ By degree of ischemia

➤Type I: (1) Type I.
a: Risk factors for cerebrovascular disease (hypertension, diabetes, hyperlipidemia, chronic cardiac insufficiency, etc.
); There are only chronic symptoms of cerebral insufficiency
.

(2) Type I.
b: it is consistent with type I.
a + paraevidence of cerebral arteriosclerosis (coronary heart disease, fundus and/or peripheral arteriosclerosis manifestations).

➤Type II: (1) Type II.
a: Type I + cerebral leukocytoporosis (accounting for 3/6 and below) and/or color ultrasound shows carotid artery abnormalities
.

(2) Type II.
b: type I + extensive leukocytosis and/or asymptomatic lacunar cerebral infarction
.

➤Type III: (1) Type III.
a: Type II.
+ irregular stenosis
of the carotid and/or vertebral basilar arteries.

(2) Type III.
b: type II.
+ carotid artery and/or vertebral basilar artery segmental or extensive occlusion
.

Description: Type I: Mainly clinical symptoms
.

Type II: General imaging changes
are added to the clinical diagnosis.

Type III: Structural changes
in blood vessels are added to type II.

The overall reflection increases with the grading, the greater
the risk of stroke.

This classification has good operability and can better reflect the gradual development of the disease
.

treat

➤ For the cause of treatment

Risk factors for the prevention and treatment of cerebrovascular diseases, such as vascular aspects (arteriosclerosis, arteritis, etc.
), hemodynamic aspects (hypertension and hypotension), blood aspects (hyperlipidemia, diabetes, high homocysteine, etc.
), and other factors (such as obesity, smoking, obstructive sleep apnea hypopnea syndrome, etc.
).


Among them, reasonable control of hypertension is one of the important links, for chronic cerebral ischemia patients with blood pressure control at what level, there is no exact standard, should be different from person to person, individualized treatment
.

➤ Recommended Program:

(1) There are no contraindications to antihypertensive pressure, and blood pressure should be reduced to less than 140/90mmHg
.

Hypertensive patients who experience intracranial aortic stenosis during the antihypertensive process can slowly and gradually reduce their blood pressure to less than
140/90 mmHg.

Long-acting drugs that do not cause electrolyte abnormalities and orthostatic hypotension such as amlodipine and irbesartan, valsartan are recommended
.

For patients with obese and inadorable hypertension with poor lifestyle habits, a novel antihypertensive drug-converting enzyme-enkephalin inhibitor may be used
.

(2) To actively correct hypopnea syndrome, the use of ventilators to assist in nocturnal sleep can be considered, and posterior pharyngeal wall plasty can also be considered to correct nocturnal hypopnea
.

(3) Actively deal with hyperhomocysteinemia, prevention and treatment of atherosclerosis, and dementia, it is recommended to use small doses of folic acid and B vitamins
.

(4) Patients with cerebral artery atherosclerosis and plaque formation can choose statins as appropriate, and active lipid-lowering therapy is also beneficial to the prevention and treatment of atherosclerosis, it is recommended to use atorvastatin, or rosuvastatin, and pay attention to monitoring liver and kidney function and muscle enzyme profile changes
.

(5) Develop good living habits, quit smoking, drinking a lot, exercise appropriately, and actively cope with high blood sugar, obesity, etc
.

➤ Medical drug treatment

Patients with clinically confirmed CCH can be given antiplatelet
aggregation, anticoagulation, circulation improvement and brain metabolites as appropriate.

➤ Improve microcirculation and promote the reconstruction of collateral circulation in the brain

Buccinthalide injection or buccinylphthalein softgels can be used for the treatment of chronic cerebral ischemia with chronic dizziness, cognitive impairment, and ataxia, and has good clinical safety and tolerability
.

➤ Surgery or intravascular treatment

For patients with atherosclerotic or inflammatory vascular stenosis (more than 70%), if the drug treatment is ineffective and there are surgical indications, carotid endarterectomy, balloon dilation, cerebral artery stenting, intracranial-external artery anastomosis, etc.
, which is one of the
important treatment measures for patients who are currently ineffective in drug treatment or have poor compensation for lateral branch circulation.

➤ Symptomatic treatment

Non-benzodiazepines dexzopiclone, zolpidem tartrate, may be given to patients with insomnia scale after evaluation using the insomnia scale
.

Memory is significantly reduced, and those
with low scale scores can be treated with methamine and donepezil.

For dizziness with aggravated position, rehabilitation guidance can be given to actively cope with dizziness and head masking
.