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Treatment of ischemic insult

Three main trends are distinguished:

I. Pharmacological

II. Physiological

III. Angioneurosurgical

/. Pharmacological agents:

Calcium channels blockers. It is known that the increase of intracellular Ca⁺⁺ content may serve as a trigger mechanism for a number of pathologic processes, including those of degradation of lipids forming a part of cell membranes, and intensification of protein catabolism.

As a result of degradation of cell membranes containing phospholip;ds, fatty acids are released and, first of all, arachidonic acid. Content of the la:ter increases in proportion to a deepening of the ischemia. The process of oxidation of arachidonic acid leads to accumulation of prostaglandins, thromboxanes, leukotrienes that cause a narrowing of cerebral vessels.

Administration of calcium channels blockers is directed to a discontinuation and weakening of this metabolic cascade. At present, such a therapy is considered as the method of influence on disturbed processes of cerebral metabolism and blood flow in the zone of ischemia.

Nimotop is introduced in the course of the first 3-5 days intravenously drop-by-drop 10 mg in 50 ml of solution as a single dose, then by 30 mg in

tablets. It improves subjective general and physical state and neurologic symptomatology intensifying cerebral blood flow.

Naloxone is the antagonist of opiate receptors in the dose of 50-5000 mg a day. It dilates cerebral vessels, intensifies cerebral blood flow, possesses antioxidant properties, changes transmembrane Ca⁺⁺ diffusion. At the same time, it elevates AP_syst, myocardial contractility, cardiac output.

Preparations contributing to improvement of cerebral metabolism:

— Nootropil in the dose up to 12-16 g a day;

— Cerebrolysin — 5-12 ml a day;

— Gammalon (aminalonum) — 2-4 tablets 3-4 times a day;

— Encephabol — 150 mg 3 times a day.

A use of the above-given medicinal agents contributes to preservation of the zone of ischemic nervous tissue and increases its resistance to hypoxia.

Thrombolysis — includes an application of fibrinolysin, streptokinase, urokinase, streptodecase and tissue plasminogen activator (TPA)

— Fibrinolysin is applied in the dose of 20-30 thnd units depending on the concentration of fibrinogen and activation of anticlotting system. It is introduced intravenously drop-by-drop with 250-300 ml of physiologic solution with addition of 10 thnd U of heparin once a day at the rate of 20-25 drops per minute;

— Tissue plasminogen activator (TPA, actilise) is introduced by 10 mg as a bolus in the course of 1-2 min, then drop-by-drop 50 mg per hour and 40 mg during subsequent 2 hours at the rate of 20 ml per hour;

— Urokinase — 1000-2000 IU/kg/hour.

Diagnosis of vascular thrombosis is being established on the basis of diagnostic subtraction angiography, and treatment is carried out by means of target administration of preparation to the thrombus through a catheter.

Perftoran is introduced intravenously drop-by-drop 6 ml/kg as a single dose in the first 6 hours since the onset of disease.

Vasoactive preparations improving cerebral blood flow:

— Complamin — 300-1200 mg, in elderly people it may lead to the failure of collateral blood flow and steal syndrome;

— Sermion — 4-8 mg intravenously drop-by-drop per 100 ml of physiologic solution, 2-4 mg intramuscularly or 5-10 mg per os. It also improves brain metabolism;

— Cavinton — 10-20 mg intravenously drop-by-drop per 500 ml of physiologic solution 2 times a day;

— Apo-plectacle, euphillin — intravenously;

— Tanakan is included in the therapy since the 3-rd — 4-th week of ischemia by 240 mg a day (80 mg 3 times) during two weeks, then by 40 mg 3 times a day with a course of treatment up to 6 months. It exerts a broad therapeutic effect on the whole system of cerebral blood circulation: arteries, veins and capillaries. In connection with this, it increases the level of cerebral metabolism, inactivates free radicals, contributes to the formation of new synapses and increase of functional activity of uninjured brain structures. As a result, this preparation has an effect on all links of pathogenesis of cerebral ischemia.

Preparations increasing a tone of veins of the brain

Therapy with vasoactive agents aimed at normalization of cerebral blood flow must stipulate a good venous outflow of blood from the brain that in insults, as a rule, is impeded. In this connection, it is expedient to use:

— Sulfocamphocainum — by 2 ml intramuscularly in every 12 hours;

— Glycerol — 1 ml/kg in enemas or per os;

— Troxevazin — 300 mg 3 times per os or 5 ml 10% solution intra­muscularly;

— Aescusan — by 20 drops 3 times per day;

— Difranel — 1 dragee 4 times a day;

— Ginkor fort — by 1 capsule 2 times a day;

— Reparil — 5-10 mg 2 times stream intravenously with subsequent change­over to tablet forms.

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