CC BY
19
Kushaeva Dildora Saidmuratovna, Tashkent Medical Academy Uzbekistan, Tashkent E-mail: kushaeva_84@bk.ru Yakubova Markhamat Mirakramovna, professor, Tashkent Medical Academy Uzbekistan, Tashkent E-mail: ktta2005@mail.ru
AGE FEATURES OF CHRONIC CEREBROVASCULAR INSUFFICIENCY IN SOME FORMS OF DYSPLASIA OF CEREBRAL ARTERIES
Abstract
Background: The aim of this study was to elucidate the age features of chronic cerebrovascular insufficiency (CCVI) in patients with different forms of dysplasia of cerebral arteries. In addition, gender features were analyzed.
Methods: We examined 61 patients, of them 20 were young (mean age 32.1±2.0 years). The control group consisted of 41 patients of middle and old age (mean age - 57.7±0.74 years). Features of clinical and neurological symptoms in different age groups were studied using paraclinical diagnostic methods, which helped to assess neurological symptoms to determine varieties of cerebral arteries lesions, depending on age.
Results: Hemodynamically significant changes were observed in hypo- or aplasias, but more often in deformations in the form of vessel inflexion at an acute angle. What is more, we observed a combination of pathological deformity (PD) and stenosis that further contributes to the development of CCVI of various degrees of severity.
Conclusions: Young adult patients were more likely to develop migraine-like headaches, especially men, whereas motor disorders, numbness in the limbs, and dizziness were typical signs for patients of middle and elderly age. Angiodysplasias in the form of hypo- or aplasias without PD in the internal carotid artery (ICA), which were often asymptomatic and had an innate nature, were observed in the young patients. PDs of ICA were noted in patients of middle and elderly age, who had stages III and IV of CCVI; they developed throughout the life on the background of hypertension, atherosclerosis and other vascular diseases.
Keywords: chronic cerebrovascular insufficiency; dysplasia of cerebral arteries; age features; diagnosis.
Introduction [5, 8, 9]. Pathology of the magisterial cerebral vessels is one of
Chronic cerebrovascular insufficiency (CCVI) is de- the most common risk factors for CCVI [6, 13]. Thus, patho-
fined as a special form of vascular cerebral pathology caused logical deformation (PD) of ICA is the second cause of de-
by slowly progressive diffuse insufficiency of blood supply to velopment of cerebrovascular insufficiency (ischemic strokes)
the brain tissue, resulting in deterioration of brain function- [7, 10], wherein concomitant arterial hypertension in patients
ing [7]. According to several researchers [2, 10, 13, 14], to increases the risk of transient ischemic attacks (TIA) [15].
date, cerebrovascular diseases remain relevant because of their The unclosed Willis circle, which is a serious anomaly, is of
rejuvenation, life-threatening serious complications such as particular importance in the occurrence of various types of
stroke, which in turn leads to profound disability of patients cerebral circulation disorders. The anatomical disconnection
with a sharp deterioration of quality of their life. Anatomi- of the circle ofWillis anteriorly is determined in 3-4% of cases
cal variations of the internal carotid artery (ICA) are diverse. that is significantly lower than posteriorly, which is 6.8-25%
Anomalies in their geometry and pathways are usually identi- [12]. In turn, the Willis circle is considered as a powerful col-
fied by ultrasound and angiography. lector that provides the distribution of blood in the brain. It
Neuroimaging studies play an important role in the diag- has been reported that the incidence of "early" atherosclero-
nosis of existing symptoms ofvascular nature: they include X- sis increases in patients younger than 40 years [3]. Neuro-
ray computed tomography scan or, more preferably, magnetic logical symptoms of cerebrovascular insufficiency manifest
resonance imaging of the brain, which provides visualization themselves as pathological tortuosity of the carotid arteries,
of consequences of acute cerebrovascular disorders and dif- affecting up to 16% of subjects studied [11]. However, the
fuse changes in white matter (leukoaraiosis). The presence clinical manifestations of crimps and stenosis in ICA are iden-
of these changes confirms a vascular nature of brain lesions tical [12]. PD of ICA is associated with various pathologies of
vertebral arteries like their PD and hypoplasia in both children and adults [4]. The linear blood flow velocity and wall shear stress in ICA decreases with age, reducing to the elderly age by 45-50%, in comparison with the period of early childhood. In 40% of patients less than 40 years, PD of ICA can lead to cerebrovascular insufficiency. Therefore, the evaluation of neurological symptoms to determine the types of lesions of cerebral arteries, depending on age, is the urgent task.
Methods
A total 61 patients were examined. Of them, 20 patients were young age from 19 to 45 years; mean age 32.1 ± 2.0 years. The control group consisted of 41 patients of middle and old age from 46 to 75 years; mean age - 57.7 ± 0.74 years. Neurological symptoms were assessed through MRI of the brain in
angioregimen and duplex scanning of brachiocephalic vessels. Duplex study was performed in 50 patients, MRI-angioreg-imen in 21 patients, and 25 patients underwent MSCT angiography. 34 patients underwent reconstructive surgery for pathological tortuosity of extracranial arteries. In other cases, patients underwent conservative treatment, which included antioxidants, metabolics, blood rheology improving agents, and cerebroprotectors. In 22 (69%) cases, pathological excesses of carotid arteries were combined with their stenosis. In the main group, men were 13 (65%) (mean age 33.2 ± 1.8 years) and women were 7 (35%) (mean age 31.2 ± 1.0 years). In the control group of patients, men were 18 (44%) (mean age 59.8±1.2 years) and women were 23 (56%) (mean age 56 ± 0.89 years) (Figure 1).
Figure 1. Age and gender gradation of patients with chronic cerebrovascular insufficiency
Statistical processing of the results obtained was carried out on standard programs of "Microsoft Excel-2007" analysis package, using indicators of evidence-based medicine (OR -relative risk, *P - Fisher exact test). The correspondence of numerical data to the normal distribution was evaluated. There were determined the selective arithmetic mean - M; the selective mean standard error (deviation) - m; the results are presented by M ± m. For the analysis of statistically significant differences between the qualitative features was used Pearson's chi-squared test (x2).
Results. When using the declared diagnostic methods of investigation, pathological tortuosity in the form of loop formation was found only in 1(3%) patients of the control group (Table 1). The incidence of inflexion at an acute angle was found in 6(43%) patients of the main group and in 15 (44%) patients of the control group. 2(14%) patients of the main group and 9 (26%) patients in the control group had Sand C-shaped crimps. It should be also noted that in patients of the control group in 22 (65%) cases, PD was combined with stenosis.
Table 1. - Findings of MRI in angioregimen and MSCT angiography for determination varieties of cerebral arteries lesions, depending on age
Findings of MRI in angioregimen n=21 Main group Young age Control group Middle and old age
1 2 3
Hypoplasia of intracranial arteries 10 (48%) 3 (14%)
Aplasia of intracranial arteries 2 (10%) 1 (5%)
1 2 3
Vascular encephalopathy without cerebral angiodysplasia - 5 (23%)
Total 21 (100%)
Findings of MSCT angiography n = 25
Aplasia of intracranial arteries - 1(4%)
Pathological deformation of extracranial arteries in combination with hypoplasia of intracranial arteries 3 (12%) 6 (24%)
Pathological deformation of extracranial arteries in combination with aplasia of intracranial arteries 1 (4%) 4 (16%)
Pathological deformation of extracranial arteries in combination with hypo-and aplasia of intracranial arteries - 4 (16%)
Pathological deformation of extracranial arteries 1 (4%) 5 (20%)
Total 25 (100%)
Hypoplasia of the intracranial arteries with MRI in angioregimen was most often observed in patients of the main group - 10 (48%) cases, in comparison with the control group - 3 (14%) cases (x2 = 4.0, P = 0.06, OR = 2.5). At MSCT angiography, PD was more often combined with angiodysplasia of the intracranial arteries, especially with intracranial arterial hypoplasia in the main group - 3 (12%) patients, while in the control group it was noted 2-fold more often - 6 (24%) patients (x2 = 0.5, P = 0.4, OR = 0.5). Isolated occurrence of PD of the extracranial arteries was also more frequently observed in the control group - 5 (20%) patients vs. only 1 (4%) case in the control group (x2 = 0.0005, P = 1.0, OR = 1.2). The majority of patients had co-morbidities such as hypertension, which was found in 9 (45%) cases vs. 4 (10%) cases in the control group
(x2 = 7.9, P = 0.006, OR = 4.6). Combination of hypertension with atherosclerosis was detected in 2 (10%) patients of the main group vs. 34 (83%) patients in the control group (x2 = 26.6, P = 0.0005, OR = 8.2). In the main group, combination of hypertension with diabetes mellitus was not observed, while it was noted in 3 (7%) patients of the control group. In 9 (45%) patients of the main group (x2 = 18.0, P = 0.0005) the disease was asymptomatic.
Analysis of neurological symptoms showed that headaches, dizziness, decreased visual acuity, memory impairment, tinnitus and head noise, numbness in the limbs, motor and speech disorders, and other signs were the main clinical manifestations in patients with CCVI (Figure 2). Patients, who had suffered transient disorders of cerebral circulation, often presented complaints of headache, dizziness, and tinnitus.
0% 20% 40% 60% 80% 100% Figure 2. Age features of clinical manifestations in patients with CCVI
In accordance with the classification of A. V. Pokrovsky (1979), the asymptomatic course (stage I of CCVI) developed in 9 (45%) cases (x2 = 18.2, P = 0.0005) and only in
patients of the main group. In patients of the control group, there was a higher prevalence of stage III of CCVI in 20(49%) patients (x2 = 2.6, P = 0.1, OR = 2.6) and stage IV of CCVI in
19 (46%) patients (x2 = 16.6, P = 0.0006). In the main group, stage III of CCVI was noted significantly lesser in 8 (40%) patients and stage IV was not observed. 52 (85%) patients had signs of cerebrovascular insufficiency of different severity. 5 (8%) patients developed TIA, 28 (46%) patients had dis-circulatory encephalopathy, and 19 (31%) patients developed ischemic stroke.
It should be noted that in 17(89%) patients, who suffered from ischemic stroke (x2 = 28.0, P = 0.0005), had combined pathology - PD with different degrees of ICA stenosis.
Table 2. - The distribution of patients with CCVI arteries (according to the findings of duplex
A surgical method of treatment was used in 63% of patients, while a conservative method was applied in the remaining 37% of patients. The indication for surgical treatment was the presence of neurological deficit: previous strokes, TIA, hemodynamically significant PD determined by duplex study, PD of ICA + all types of plaques, narrowing the vascular lumen by more than 60%, PD of ICA + embologenic plaque. Duplex scanning of the brachiocephalic arteries (BCA) was performed in 50 (82%) patients.
by varieties of angiodysplasia of the cerebral scanning of the brachiocephalic arteries)
Types of crimps Main group N = 14 Control group N = 36
C- and S-shaped crimps 2(14%) 8(22%)
Bends at an acute angle 6(43%) 15(42%)
Loop formation - 1(3%)
Different variants of crimps 1(7%) 1(3%)
Stenosis, occlusion of extracranial arteries 1(7%) 9(25%)
Norm 4(29%) 2(5%)
Total 14(100%) 36(100%)
Of occurring types of angiodysplasias of ICA, bends at an acute angle were more frequently observed in the control group in 15 (42%) cases (kinking) vs. 6 (43%) cases in the main group (Table 2.). S- and C-shaped crimps were noted lesser, their incidence was also prevailed in the control group in 8 (22%) of 36 patients vs. 2 (14%) cases in the main group.
The linear blood flow velocity of ICA averaged in the main group 126.6 ± 12.8 cm/sec in the right, 101.5 ± 7.6 cm/sec in the left, whereas in patients of the control group it averaged 122.6 ± 5.1 cm/sec in the right, 127.2 ± 8.2 cm/sec in the left. This was also an indication for surgical treatment.
Discussion
Clinical manifestations and development of CCVI in different age groups are variable. Some authors reported the frequent incidence of stable hypertension in patients less than 55 years, while the combination of hypertension and atherosclerosis was significantly often noted in elderly people [1]. Our data corresponds to the data that hypertension was more common at younger age, atherosclerosis and hypertension at middle age and the elderly, who have CCVI of different severity. At the same time, hypertension increases the risk of CCVI by 4.6 times, in combination with atherosclerosis by 8.2 times. L. Manvelov (2014) also believed that hypertension increases the risk of stroke by 3-4 times. According to V. V. Kakharchuk (2005), hypertension in combination with atherosclerosis increases the death rate from cardiovascular diseases by 3 times. There are PDs of ICA isolated or combined with pathology of the vertebral arteries. According to P. O. Kozachyan and
M. A. Lobov (2009), 30% of patients with PD of ICA had its combination with abnormalities of the vertebral artery. In our studies, this combination amounted 20% in the main group and 34% in the control group. According to A. V. Pokrovsky et al. (2011), the linear blood flow velocity in the deformation zone varied from 60 to 350 cm/sec regardless of the form of PD. In our patients as well, the linear blood flow velocity in the main group varied from 60 to 320 cm/sec vs. from 56 to 291 cm/sec in the control group. The linear blood flow velocity in the area of PD of ICA in both groups did not differ much, even in spite of differences in age. This can be explained by the fact that young patients had PD in the form of inflection at an acute angle. In addition, there was the combination of PD with hypo- or aplasias of the intracranial arteries, and this increased the risk of development of CCVI by 8.2 times. We assume that, such changes probably lead to decrease in cerebral blood flow and further to cerebrovascular insufficiency.
Conclusions
Clinical and diagnostic manifestations of CCVI such as headaches, mostly migraine-like headaches, were predominant in young patients, especially in men, whereas motor disorders, numbness in the limbs, and dizziness, in addition to headaches, were typical signs for patients of middle and elderly age.
According to the diagnostic tests, angiodysplasias in the form of hypo- or aplasias without PD in ICA were observed at the young patients and often were asymptomatic. PD of ICA was isolated in patients of middle and elderly age, who had stag-
es III and IV ofCCVI. It was established the risk of CCVI occur- and they did not manifest themselves clinically for a long time.
rence, which increased in 8.2 times in patients with angiodys- In patients of middle and elderly age, PDs develop throughout
plasias of the intra- or extracranial arteries. In young patients, as the life on the background of hypertension, atherosclerosis and
determined, extracranial angiodysplasias had an innate nature other vascular diseases and more often affects the ICA.
References:
1. Bakunts G. O. Endogenous factors of cerebral stroke. In Russian. - Moscow: GEOTAR-Media; - 2011.
2. Erkebaeva A. E. Improvement of hemodynamics in cerebrovascular insufficiency by acupuncture. Medicine.- 2013; 4: 26-27.
3. Lemenev V. L., Siluyanova A. S., Shamshilin A. A., Akhmetov V. V. The choice of method of vascular reconstruction in patients with pathological tortuosity of the internal carotid artery. Neurosurgery.- 2014; 3: 42-49.
4. Lisovsky E. V., Evtushenko O. S., Yavorskaya O. L., Evtushenko S. K. Neurovascular form of congenital weakness of connective tissue in children. Bulletin of physiotherapy and balneology.- 2005; 11: 26-27.
5. Mkhitaryan E. A., Preobrazhenskaya I. S. Alzheimer's disease and cerebrovascular disorders. Neurological Journal.- 2006; 11(1): 4-12.
6. Pokrovsky A. V., Beloyartsev D. F., Timina I. E., Adyrkhaev Z. A. Clinical manifestations and diagnosis of pathological deformation of the internal carotid artery. Angiology and vascular surgery.- 2011; 17(2): 7-18.
7. Pokrovsky A. V., Beloyartsev D. F., Adyrkhaev Z. A. Late outcomes of reconstructive operations for pathological deformation of the internal carotid artery. Angiology and vascular surgery.- 2012; 1: 92-104.
8. Yakhno N. N. Cognitive disorders in the neurological clinic. Neurological Journal.- 2006; 11(1): 4-12.
9. Yakhno N. N., Levin O. S., Damulin I. V. Comparison of clinical and MRI data in discirculatory encephalopathy, Message 2: cognitive impairment. Neurological Journal.- 2001; 6(3): 10-19.
10. Barbera G. L., Marca G., Martino. Kinking, coiling, and tortuosity of extracranial internal carotid artery: is it the effect of a mrtaplasia? Surg Radiol Anat.- 2006; 28: 573-580.
11. Beigelman R., Iraquirre A. M., Robles M., Grana D. R. Kinking of carotid arteries is not a mechanism of cerebral ischemia: a functional evaluation by Doppler echography. Int. Angiol.- 2011; 3 (4): 342-48.
12. Benes V., Mohapl M. Alternative surgery for the kinked internal carotid artery. Acta Neurochirurgica.- 2001; 143: 1267-71.
13. Dafer R. M., Biller J. Nonatherosclerotic cerebral vasculopathies. Stroke in Children and Young Adults. 2nd ed. Philadelphia: Elsevier Health Sciences. - 2009.
14. Mumoli N., Cei M. Asymptomatic carotid kicking. Circ. J.- 2008; 72(4): 682-683.
15. Pancera P., Ribul R., Presciuttini B., Lechi A. Prevalence of carotid artery kinking in 590 consecutive subjects evaluated by Echocolordoppler. Is there a correlation with arterial hypertension? Journal of Internal Medicine.- 2010; 248: 7-12.
