Cerebral infarction
I. Western medical diagnosis name: cerebral infarction; Chinese medical diagnosis name: stroke disease
Definition (including the scope of diagnosis in Chinese medicine): It is a disease caused by the occurrence of blood clots, emboli or other causes of insufficient blood supply to the brain in the cerebral vessels. Cerebral infarction includes the common cerebral atherosclerotic thrombotic cerebral infarction (referred to as cerebral thrombosis) and cerebral embolism. Cerebral infarction is equivalent to stroke in Chinese medicine. Stroke is a disease characterized by sudden fainting, unconsciousness, hemiplegia, slanting of the mouth and eyes, and unfavorable speech. The main symptom is slanting of the mouth and eyes and unfavorable speech. In milder cases, there may be no fainting but only paralysis and slanting of the mouth and eyes. Slanting and other symptoms. Because of the sudden onset of the disease, the onset of the disease is rapid, “like a rock in the midst of a vector, like the rapidity of a storm.” The clinical symptoms are different, changeable and rapid, with fainting and convulsions, similar to the characteristics of “wind is good at moving and changing” in nature, so the ancient doctors took the analogy and named it “stroke”; because of its sudden onset, it is also called It is also called “stroke” because of its sudden onset. Chen Chao, Department of Emergency Medicine, Shanghai Hospital of Traditional Chinese Medicine
Etiology and pathology
1. Western medical etiology
(1) Thrombosis: due to the narrowing of the lumen of cerebral arteriosclerosis, resulting in the slowing down of blood flow thrombosis. It occurs in the middle cerebral artery branches, such as the doublestem artery.
(2) Embolism caused by: the most common of them is cardiogenic (atrial fibrillation, myocardial infarction, heart valve disease, endocarditis, heart enlargement, heart failure, etc.), accounting for 45%, and the remaining 5% may come from atherosclerotic fragmented plaque shedding, arterial inflammatory emboli and fat embolism and air embolism, etc. Although cerebral thrombosis and cerebral embolism can be caused by different etiologies, both pathophysiologically cause cerebral vascular occlusion and cerebral ischemic changes, so they are basically the same in terms of treatment.
2.TCM etiology and pathogenesis.
The basic pathogenesis of this disease is always the imbalance of yin and yang and the rebellion of qi and blood. The disease is located in the heart and brain, and is closely related to the liver and kidney. The Su Wen? The “Pulse to the Essence” says: “The head is the house of the essence.” Li Shizhen also pointed out in the “Compendium of Materia Medica” that the brain is the “House of the Essence”. Both “Jingming” and “Yuan Shen” refer to the function of mastering mental consciousness and thinking activities, so it can be considered that Shenming is the master of the mind and brain. The pathological basis is Yin deficiency of the liver and kidney. The deficiency of liver and kidney yin makes it easy for liver yang to become hyperactive, and when combined with improper diet and living, emotional stimulation or external evil, the qi and blood rush up to the brain and the nerves are blocked, so the patient suddenly faints and becomes unconscious. The pathological factors are mainly wind, fire, phlegm and stasis, and their formation is related to the dysfunction of the internal organs. For example, liver and kidney yin deficiency, hyperactivity of yang to fire and wind, or five will to fire and wind. The spleen is not healthy, phlegm is generated, or fire and heat refine liquid into phlegm. The stagnation of blood stasis can be caused by anger and blood aster on the top, or Qi deficiency and inability to push. The four can affect each other or see the same disease, such as wind and fire incite each other, phlegm and blood stagnation and so on. In severe cases, the wind, Yang, phlegm, fire and qi and blood block the brain orifices and run across the meridians, resulting in fainting, aphasia, and? The patient may become faint, aphasic, and unstable. The nature of the pathology is mostly deficient in nature and real in symptoms. Liver and kidney yin deficiency, qi and blood weakness is the root of the disease, wind, fire, phlegm, qi and stasis are the symptoms of the disease, and they can be mutually causal. At the beginning of the disease, the evil is scops, the wind, Yang, phlegm, and fire are strong, and the qi and blood are on the top, so the standard is mainly real; if the disease changes drastically, under the fierce attack of the evil, the positive qi collapses rapidly, so the positive deficiency can be the main cause, and even the deficiency of positive qi appears. In the later stage, because the positive qi is not restored and the evil qi remains alone, it can leave sequelae.
The evidence can be divided into.
(1) middle meridians and collaterals (lesions are limited to blood vessels and meridians, clinical manifestations are mild without mental changes)
(1) deficiency in the middle meridians and channels, wind evil into the middle: the symptoms are distorted eyes and mouth, salivation at the corners of the mouth, unfavorable language, or even partially paralyzed, usually the skin is not benevolent, numbness of the hands and feet or vicious cold, fever, limb restraint, aching joints, white moss, floating pulse.
② liver and kidney yin deficiency, wind and yang up disturbance type: symptoms see hemiplegia, distorted mouth and eyes, unfavorable language, partial body numbness, or also see dizziness and headache, tinnitus and dizziness, less sleep and more dreams, red tongue with yellow greasy coating, pulse string thin count or string slippery.
(iii) Qi deficiency and blood stasis, stasis of veins and ligaments type, see hemiplegia, limb weakness, accompanied by swelling of the affected side of the hands and feet, unfavorable language, distorted mouth and eyes, withered face, or dull and dull, thin white tongue coating, light yellow tongue, thin and astringent pulse, etc.
(4) Wind-phlegm blocking type: symptoms include strong tongue and speech, numbness of the limbs, slippery pulse, etc.
(2) in the internal organs (the lesion affects the relevant internal organs, often with confusion and heavy illness)
(1) Internal closure of evil: Liver Yang is violent, Yang rises and wind moves, Qi and blood are reversed, and phlegm and fire are carried up to the clear orifices. This can be seen as sudden fainting, unconsciousness, red face and body heat, silent mouth and constipation. The coating is yellow and greasy, and the pulse is slippery. Or phlegm and dampness, wind and phlegm and dampness, upward obscuring the clear orifices and closing the meridians and collaterals, sudden fainting, not waking up, teeth closed, mouth silent, hands clenched, urine and stool closed, strong spasms of limbs, white face and lips dark, limbs not warm, phlegm and saliva congested. The coating is white and greasy, and the pulse is sunken and slippery.
② yin exhaustion and yang off: yang floating on top, yin exhaustion on the bottom, deficiency of positive energy, the mind and spirit decay, yin and yang have the potential to leave the decision, can be seen suddenly faint, unconscious, eyes closed mouth open, hand urination, breathing weak, sweating limb syncope. The pulse is weak or weak and wants to die.
IV. Clinical manifestations
1. Most of the cases have a sudden onset, and some cases have TIA episodes before the onset.
2. Clinical signs and symptoms of focal neurological deficits, such as hemiparesis, hemianesthesia, hemianopsia, aphasia, vertigo, dysphagia, ataxia, etc.
3, The onset may be without/ or with mild impairment of consciousness, with progressive aggravation in some cases.
4. NIHSS assessment of neurological deficits and evaluation of dysphagia (Kubota drinking test) are given.
Among the clinical staging are (OCSP staging)
(1) Complete anterior circulation infarction (TACI): manifests as complete middle cerebral artery (MCA) syndrome: impairment of higher neural activity in the brain (impaired consciousness, aphasia, aphasia, spatial disorientation, etc.), isotropic hemianopia, and more severe activity and/or sensory impairment contralateral to the lesion. Mostly proximal segmental trunk of the MCA, and in a few cases, large brain infarcts caused by occlusion of the siphon segment of the internal carotid artery.
(2) Partial anterior circulation infarction (PACI): two of the above triad signs are present, or only higher neural activity impairment, or sensory-motor deficits are more limited than TACI. It is suggested to be a medium or small infarct caused by occlusion of the distal trunk of the MCA, branches at all levels or ACA and branches.
(3) Posterior circulation infarction (POCI): manifests as various degrees of vertebral-basilar artery syndrome: it may manifest as ipsilateral cerebral nerve palsy and contralateral sensorimotor deficits; bilateral sensorimotor deficits; bilateral co-ocular activity and cerebellar dysfunction. Brainstem and cerebellar infarcts of varying sizes caused by occlusion of vertebral-basilar arteries and branches.
(4) Lacunar infarction (LACI): manifests as lacunar syndromes, such as pure motor hemiparesis, pure sensory stroke, ataxic mild hemiparesis, and clumsy hand-poor dysarthria syndrome. Most of them are small cavernous foci caused by lesions of small penetrating branches of the basal ganglia or cerebral bridge.
V. Laboratory and other tests
Cranial CT, routine blood, emergency biochemistry, and coagulation tests are completed within 45 minutes. Cranial CT mostly has no obvious changes within 24h, and low-density foci in the infarct area can be seen after 24h-48h; cranial MRI can detect infarct foci early, with low signal in T1 and high signal in T2, and diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) can help determine the ischemic semidark zone; non-invasive examinations such as magnetic resonance angiography (MRA) and CT angiography (CTA) are useful for finding non-invasive examinations such as magnetic resonance angiography (MRA) and CT angiography (CTA) are useful for finding the cause.
Diagnosis and differential diagnosis
1.Western medical diagnosis.
(1) Those with signs and symptoms of cerebral arteriosclerosis, and the first occurrence is over 45 years old.
(2) The causes of intracranial tumor, inflammation, poisoning, trauma, etc. are excluded.
(3) There is a history of hypertension, especially stage II or above.
(4) There are signs of arteriosclerosis of the fundus.
(5) Those with certain atherosclerosis in the cardiovascular system and other areas: clinical and electrocardiographic changes of coronary atherosclerosis, X-ray signs of aortic atherosclerosis, murmurs of carotid and subclavian arteries, signs of radial, temporal and dorsalis pedis arteriosclerosis.
If all of these aspects are present, cerebral arteriosclerosis can be clinically identified. If you have only 1 or 2, but not all 3, 4 or 5, the following auxiliary examinations should be performed: ①Lipid determination, cholesterol > 200-250mg%, triglyceride > 130mg%, beta lipoprotein > 450-600mg%. ②Cerebral hemogram, including drug test. ③Electroencephalography, including neck compression evoked test. ④Cerebral angiography if necessary. ⑤ Local blood flow measurement when available.
Notes.
①If only certain symptoms and signs are present and not all of the above diagnostic criteria are present, the diagnosis will be further confirmed by follow-up examination as suspected cerebral arteriosclerosis.
②When only symptoms and signs are present, and other neurological examinations and auxiliary tests are negative, it is recommended to diagnose according to symptoms, such as neurasthenia syndrome, dementia syndrome, and to continue observation to trace the cause.
③In the process of census or diagnosis of other diseases, if physical signs of cerebral atherosclerosis and certain auxiliary examinations are found to be clearly positive, even though there are no brain symptoms and signs, it should be diagnosed as the asymptomatic stage of cerebral atherosclerosis, and timely prevention and treatment.
④ Patients who already have a history of mini-stroke or major stroke attack should be treated as acute cerebral blood circulation disorder. If the cause of stroke is cerebral arteriosclerosis and the above criteria are met, cerebral arteriosclerosis should be diagnosed and prevented and treated.
⑤ This criterion is only suitable for clinical application in middle-aged and elderly people. For cerebral arteriosclerosis, symptomatic hypertension, and cerebral comorbidities under 45 years of age, they are diagnosed and treated according to specific conditions.
2. Western medical differential diagnosis.
(1) Differentiation from cerebral hemorrhage: cerebral hemorrhage onset state mostly in agitation, activity, blood pressure significantly increased, common symptoms such as headache and nausea, increased pressure in cerebrospinal fluid, containing blood, high-density brain shadow visible on CT examination.
(2) Intracranial occupying lesions: intracranial tumor or brain abscess can also be acute and cause focal neurological deficits, similar to cerebral infarction, and brain abscess can have a history of infection in other parts of the body or systemic infection. CT and MRI of the head can help to make a clear diagnosis.
3. Chinese medicine diagnosis points.
(1) The main symptoms are confusion, disorientation, even coma or dizziness, hemiplegia, slanting of the mouth and tongue, strong tongue or incoherent speech, and numbness of the partial body.
(2) The onset of the disease is mostly acute.
(3) The onset of the disease is often precipitated by dizziness, headache, numbness and weakness of the limbs before the onset of the disease.
(4) The age of onset is more common than 40 years old.
(5) Cerebrospinal fluid examination, fundus examination, cranial CT, MRI and other examinations are helpful for diagnosis.
(5) Cerebrospinal fluid examination, fundus examination, cranio-cerebral CT, MRI, etc. can help to diagnose. The internal organs are the ones with hemiplegia, distorted mouth and tongue, strong tongue and numbness, mental trance or disorientation, while the middle organs must have mental faintness or dizziness and see hemiplegia, distorted mouth and tongue, strong tongue and numbness. During the evolution of the disease, the meridians and internal organs can be transformed into each other.
The acute phase of stroke disease is within two weeks after the onset of the disease, the longest period of disease in the internal organs can be up to 1 month, the recovery period refers to 2 weeks after the onset of the disease or 1 month to within six months; the sequelae period refers to more than six months after the onset of the disease.
4, Chinese medicine class evidence to distinguish.
Differentiation from impotence: impotence can have limb paralysis, weakness of movement and other manifestations similar to stroke; for those who cannot recover from hemiplegia for a long time after stroke, impotence can be seen as muscle thinning and tendon relaxation, and the two should be differentiated: however, impotence generally starts slowly, with double lower limb paralysis or quadriplegia, or muscle atrophy, and muscle tigers and flesh trapped; whereas limb paralysis in stroke has a rapid onset and is mainly hemiplegia. In impotence, there is no dizziness at the onset of the disease, while in stroke, there is often varying degrees of dizziness.