06 April 2018

Brain and blood vessels

Vladimir Zakharov: "There are no strokes in a healthy person"

Anna Kerman, XX2 century

Doctor of Medical Sciences, Neurologist of the Yusupov Hospital Vladimir Zakharov told in an interview with the portal "XX2 century" about what subcortical vascular pathologies are, why there is a stroke, and most importantly – how to delay the onset of these problems without dietary supplements, registration and SMS. That is, by means of evidence-based medicine.

XX2 CENTURY. Vladimir Vladimirovich, today we are talking about disorders of the blood supply to the brain and what they lead to. But first I would like to clarify how common vascular disorders are. Is this really a massive problem or are we talking about individual cases that make a minimal contribution to the overall structure of cognitive and other brain disorders?

V. Zakharov. This question only seems simple and superficial. The fact is that a very interesting situation has developed in Russian clinical medicine. The "favorite" diagnosis of neurologists and many other specialists in our country is "chronic cerebral ischemia" or "dyscirculatory encephalopathy". This diagnosis is unknown outside our fatherland, it simply does not exist.

And here I ask the doctors: "How often do you have chronic cerebral ischemia at the reception, if we take people over 50 years old?" They say: "70%". Of course, this is not any science, because no one has conducted epidemiological studies, but so, offhand, 50-70% of patients are called. That is, two-thirds of patients over the age of 50 receive this diagnosis. Why? Because patients over the age of 50 mostly suffer from hypertension, atherosclerosis and other vascular diseases. The patient can come to the doctor with any complaint: headache, dizziness, maybe his nose itched. But if he has hypertension and atherosclerosis, he will immediately hear: "It's all vascular." Endless medications are prescribed that supposedly "clear the vessels" and "improve cerebral circulation."

Maybe there is some rational grain in this tradition. Because many patients like this approach, and, most importantly, not just like it, but helps. The so-called vascular drugs help with the same headache and dizziness. The question is why they help. How does it work?

In fact, these patients suffer from asthenic disorders. Asthenia, anxiety, depression and everything that is called "borderline psychopathology". And here a person with upset nerves, with an increased level of anxiety, with sleep disorders, with headaches comes to the doctor – what should he prescribe?

XX2 CENTURY. Antidepressants? But the patient is likely to be offended.

V. Z. Firstly, he will really be offended. And secondly, he most likely will not take them, because there is a prejudice in society against this class of drugs. And most importantly, by and large, most of these patients do not need any antidepressants. This symbolic prescription of drugs and "laying on of hands" is often enough to make a person really feel better. Of course, if we are talking about psychasthenic disorders.

XX2 CENTURY. And how are things with this in international clinical practice?

One of my colleagues, who used to live in Russia and now abroad, said: "If our patient had been treated the way they are treated according to international standards, the doctor would have received 100 complaints about himself in the first week."

Therefore, in the Russian tradition of prescribing vascular drugs, maybe there is something from a practical point of view, I'm not saying that this is an absolutely bad approach. Maybe even our Western colleagues should learn something from us. But the fact that these appointments have little real relation to vascular diseases of the brain is a fact. In most cases, vascular drugs in our country are received by elderly people, maybe with mild cognitive disorders, mainly with asthenic disorders, with upset nerves. And it helps such patients, first of all, the attention from the doctor and the awareness that their problems were taken seriously, they began to be treated.

XX2 CENTURY. And what about vascular disorders, then?

V. Z. Vascular diseases of the brain are two positions. The first is a stroke, the second is subcortical vascular dementia or pre–dementia cognitive disorders. Stroke is a common pathology. Every year there are 20 million new cases of stroke in the world. Subcortical vascular pathology – leukoencephalopathy – is actually not as common as we think. Most of the changes on the MRI that are detected are not clinically significant, they do not manifest themselves in any way. Therefore, this subcortical variant of vascular cognitive disorders in the structure of dementia occupies about 10%. And the most important cause, Alzheimer's disease, is the cause of about 50% of dementia cases. That is, vascular cognitive impairment is five times less common than Alzheimer's disease.

XX2 CENTURY. You mentioned stroke as one of the vascular disorders. Tell me, are there any "harbingers" of a stroke, symptoms and signs by which you can suspect its approach?

V. Z. No. A harbinger, or even not a harbinger, but the cause of a stroke is a disease of the cardiovascular system. If they are, there is also a high risk of stroke. In the first place among such diseases is arterial hypertension. This is the most important risk factor for both stroke and the notorious chronic cerebral ischemia, if we keep in mind subcortical cognitive disorders. Maybe atrial fibrillation will compete with hypertension. If there is atrial fibrillation, the risk of stroke is very high. The same applies to atherosclerosis of the cerebral arteries. These diseases themselves do not have any obvious symptoms at the beginning of their development. Therefore, every person, starting from the age of forty, should check blood pressure, glucose, cholesterol in the order of medical examination. Simple things, there is nothing special here.

If blood pressure starts to rise, then you need to take medications in a timely manner and in advance, and not wait for trouble to happen.

XX2 CENTURY. But surely the increase in pressure has some symptoms?

V. Z. This is a very common opinion that is being refuted today. Allegedly, an increase in blood pressure is necessarily accompanied by headache or dizziness. In fact, such symptoms appear in a single case, if very quickly, within half an hour, for example, the pressure rises by several tens of millimeters of mercury. Then the patient can feel it. In other cases, there will be no dizziness, no headache, no noise in the head, no fatigue, or any other subjective neurological symptoms.

XX2 CENTURY. But if the presence of hypertension cannot be judged by the state of health, how can it be detected? After all, many people say "I have a working pressure of 150/100, I feel fine."

V. Z. There are clear criteria for arterial hypertension. A pressure of 140 over 90 mm Hg is already considered hypertension, and it is already associated with an increased risk of vascular events, in particular, the same strokes.

The term "working pressure" does exist. I do not know who introduced it into medical use, but I really do not like this concept – it is ambiguous and misleading. For any age, for any patient, the upper limit of the norm of 135/85. 140/90 is already pathology. It doesn't matter how a person feels at the same time. He can feel great at a pressure of 200/150, nothing will bother the patient until a stroke or heart attack occurs. Therefore, well-being is not a guideline or indicator for us in this case.

Indeed, if blood pressure is normalized too quickly, then a hypertensive person with experience may feel bad. In this case, there is a generally accepted recommendation of cardiologists – to reduce the pressure gradually. That is, not in a week, but in five or six weeks, and even in three months, there is no hurry. If a person has been suffering from hypertension for 10 years, an extra three to six months will not significantly increase his risks. Nevertheless, we must go towards the targets.

The target indicator is blood pressure below 140/90, it must be achieved. If it is not achieved, then we can assume that we are not treating, but pretending to treat. The only exception to this rule is patients with hemodynamically significant carotid artery stenosis, in whom more than 70% of the carotid arteries are blocked by atherosclerosis. We are not trying to achieve their targets, because it may not be safe for the brain.

XX2 CENTURY. Is there anything other than absolute blood pressure indicators that the patient needs to focus on?

V. Z. Yes, there is. In second place in importance is the variability of pressure. It's bad when it's low and high during the day. And in this regard, it is very important to carry out explanatory work with the patient, to tell him that medications for pressure should be taken not when it has increased, but up to this point. But sometimes even doctors encourage this behavior: first measure the pressure, and if it is normal, then skip taking medications. What if it falls even lower?

I always recommend my patients to measure their blood pressure at different times of the day. For one, it rises in the morning, for the other in the evening – and if measurements are taken all the time at the same time, such "peaks" can be missed, not noticed.

XX2 CENTURY. And thereby increase the risk of stroke. But after all, in addition to strokes, there are also so-called transient ischemic attacks. Are they dangerous for our brain?

V. Z. Acute disorders of cerebral circulation are divided into strokes and transient ischemic attacks. Whether we are talking about a stroke or an ischemic attack, we determine by the duration of symptoms, with transient attacks it is less than a day (this is a formal criterion, in fact, symptoms during an attack can last only a few minutes). And the second dividing criterion is the absence of infarction (organic damage) of the brain during neuroimaging. That is, if we are talking about a transient attack, the patient has not formed a heart attack. But in fact, this is the same stroke, just not completed, a stroke that began, and then for some reason did not end as it should.

However, if it has not ended now, then no one can guarantee that it will not end tomorrow. Therefore, the presence of a history of transient ischemic attacks at times, ten times increases the risk of stroke. And the management of patients with such attacks is no different from the management of stroke patients – we prescribe the same treatment.

XX2 CENTURY. Are transient ischemic attacks dangerous from the point of view of cognitive impairment?

V. Z. Of course. There is a concept of "predictor" and there is a concept of "risk factor". A risk factor is an event that is causally related to another event. For example, arterial hypertension is a risk factor for stroke. And the predictor is not necessarily in a causal relationship. For example, atherosclerosis of the lower extremities is associated with an increased risk of stroke. Not because atherosclerosis of the legs causes a stroke, but because if there is atherosclerosis in the legs, then it will be in the neck. This is a systemic disease. Therefore, it is an indicator, but not a risk factor. I can say the same about a transient ischemic attack.

Moreover, I can say the same about a stroke. Stroke does not always lead to the development of cognitive impairments by itself, and even if it does, as a rule, they are local in nature. For example, the speech center is damaged – aphasia develops, which may or may not regress later, depending on the volume and localization of the focus. If extensive cognitive impairments develop after a stroke, this indicates the presence of other pathologies that previously could not manifest themselves in any way.

Therefore, naturally, in patients with these events, with transient attacks or stroke, the detectability of subsequent memory disorders and other cognitive disorders reaches 80% or more. A third of these 80% is Alzheimer's disease, paradoxically. In fact, nothing surprising, because the vascular event that has occurred is superimposed on the silent stage of the neurodegenerative process and how the trigger triggers clinical manifestations, how the trigger acts.

That is, Alzheimer's disease was already there before the stroke or attack – it simply did not manifest itself in any way. It is known that for at least 10 years from the onset of the disease, it is "silent" – our brain is created with a large reserve, it has large reserves. But even a small vascular event can decompensate this system.

It is important to understand that there are no strokes in a healthy person. If a stroke occurred, most likely, almost certainly, the patient already had vascular leukoencephalopathy, a lesion of the white matter of the brain. Like neurodegenerative diseases, leukoencephalopathy may not manifest itself for years.

XX2 CENTURY. But how to identify the diseases you are talking about if they do not declare themselves in any way, if they have been "silent" for years?

V. Z. We cannot suspect their presence in any way. Only by the presence of risk factors. If a person has hypertension or other vascular diseases, then, in general, some pathological processes in the brain are already implied. And the first noticeable symptoms are cognitive impairments.

XX2 CENTURY. Forgetfulness?

V. Z. No, forgetfulness is the first symptom of Alzheimer's disease. And now we are talking about subcortical disorders, they do not begin with memory disorders, but with attention disorders. People find it difficult to concentrate, they get tired faster.

Interestingly, patients themselves often describe their condition as "unpleasant sensations in the head." They say that she "became some kind of cast-iron" or "I walk as if I was hit on the head with a dust bag." But all this means that it is difficult for a person to concentrate, it is difficult to get involved in any work, as if the head "does not want to work."

XX2 CENTURY. And yet, what can be done to make the head always "want to work"? More precisely, what are the preventive measures that allow, if not to reduce the risk of developing vascular pathologies to zero, then at least delay their onset?

V. Z. Everything is banal, there are no secrets here. It's very simple. Physical and mental activity, healthy lifestyle, timely diagnosis and treatment of vascular diseases.

Physical activity promotes the synthesis of neurotrophic factors that protect the brain. There are a lot of studies on this topic that show that someone who moves a lot, thinks well and for a long time. And mental activity is the reserve that we accumulate. The more extensive this stock is, the more the disease must work hard for symptoms to appear.

And the second, no less important point. Since a lot depends on genetics, and not on lifestyle, timely diagnosis and treatment of vascular diseases that are genetically determined is necessary. Starting from the age of 40, it is necessary to check blood pressure, cholesterol, sugar. If something is detected, it needs to be treated, fortunately, these are all things that can be corrected.

They say that up to 90% of strokes can be prevented. This also applies to vascular cognitive disorders. Vascular diseases are treated poorly, but are prevented today, I must say, quite effectively.

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