Cévní mozkové příhody - terapie

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

Deprecated: Function split() is deprecated in /home/users/dana/medicinman.cz/web/csf/kf.inc.php on line 67

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Neobstrukční mozkové ischémie

• Hypoxie
• Anoxie
• Resp. selhání
• Plicní embolie
• Asfyxie
• Intoxikace CO2
• Srdeční selhání
• Hypovolemie
• Hypotenze protrahovaná
• hypoglykémie
• Zvýšení viskozity krve
• Polycytemie
• dehydratace
• Zvýšená rigidita krvinek aj. [1]

Hypoxicko-ischemická encefalopatie

• Interteritoriální infarkty
• X bazální ganglia
• Manisfestace často v klidu v noci nad ránem
• Fyziologický pokles TK
• Příznaky ložiskové - dle locus minoris resistentiae
• Selektivní vurneabilita mozkové tkáně
• Mozkové infarkty mohou proběhnout i asymptomaticky
• Detekce možná až na CT / MR [1]

Chronické vaksulární poruchy CNS

• Kulmualtivní efekt
• X paměti
• X koncentrace
• X pozornosti
• X zpomalení PM tempa
• X afektivity
• Emoční a depresivní rozlady
• Změny osobnosti
• Snížené adaptační rezervy - snadná dekompenzace a projevy dle locus minoris resitentiae
• Teplota
• dehydratace
• Po operaci, traumatu
• Resp. insuficienci
• Anemie
• Hypovolémie
• Vyšší dávky diuretik aj.
• Důsledky dekompenzace
• Noční zmatenosti s neklidem až agitací
• Spánková inverze s útlumem během dne

Vaskulární demence

• Multiinfarktová demence
• Infarkt v oblasti
• Thalamu
• A. cerebri posterior a anterior
• Rozvoj obvykle do 3 měs. po iktu
• I náhlý vznik
• Fluktuující symptomatika a progrese
• Lakunární demence
• Biswangerova choroba (demence)
• Léze periventrikálárně v bílé hmotě - centrum semiovale
• Smíšené lakunární léze, léze periventrikulární a bazálních ganglií

Sdružené poruchy

• často x chůze - frontální typ
• Pseudobulbární syndrom
• Parkinsonské syndromy
• Inkontinence
• Mozková atrofie [1]

Zdroje informací:

[1] AMBLER, Zdeněk. Základy neurologie. 6. vydání. Praha : Galén, 2006, vydáno v r. 2007, 352 stran. ISBN 80-7262-433-4.

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Terapie akutního stádia hemoragické CMP

• Subakutně terapie na záchranu perifokálních ložisek je stejná jako u ischemie !!! [1]
• Kontraindikována antikoagulancia !

Rehabilitace

• Také co nejdříve ! [1]

Operace

• Expanzivní mozečkové krvácení
• Exp. supratentoriální hemoragie - vypuštění hematomu
• Hlavně netříštivá krvácení [1]

Dýchání

Metabolismus

Prevence trombembolismu

Srdeční činnost

Korekce hypertenze

• Pomalu a opatrně [1]

Terapie intrakraniální hypertenze

Terapie mozkového otoku [1]

Terapie chornického stádia po CMP

Reziduální neurologický deficit

• Spastická hemiparéza
• afázie, dysartrie
• Závratě, x rovnováhy
• Fáze úprav deficitu obvykle 3-6 měsíců
• Teprve poté konečné reziduum [1]

Vaskulární demence

• Přeevším x paměti [1]

Antitrombotická terapie všech

• ASA 50-325 mg /d ráno nalačno
• Blokáda tromboxanu
• ASA s dipyridamolem s modifikovaným uvolňováním (Aggrenox)
• V terapii ICHDK dipyridamol efekt jako placebo a ASA v Aggrenoxu je jen málo. Pochybuji o smyslu tohoto preparátu.
• Clopidogrel 75 mg /d - derivát thienopyridinu (Plavix)
• Blokáda rec. pro adenozindifosfát při aggr. trombocytů = brání aktivaci IIb/IIIa na povrchu trombocytů
• Při intoleranci ASA, po selhání terapie ASA / Aggrenox
• Ticlopidin (Ticlid, Tagren, Apo-Tic)
• Blokáda fosfolipázy C
• NÚ neutropenie
• Indobufen (Ibustrun)
• Warfarin
• U vys. rizika trombembolie k INR 2-3

Hypolipidemika

• Lovastatin
• Simvastatin [1]

Zdroje informací:

[1] AMBLER, Zdeněk. Základy neurologie. 6. vydání. Praha : Galén, 2006, vydáno v r. 2007, 352 stran. ISBN 80-7262-433-4.



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Terapie akutního stadia ischemické CMP

• Záchrana zóny funkčního deficitu kolem ischemického ložiska
• Terapie co nejdříve - dokud zachován metabolismus tkáně

Neuroprotekce

Minimalizace cévní okluze

Reperfúze

Prevence reperfúzního poškození

Prevence hyperexcitace

Zajištění respirace

• Ihalace kyslíku
• Intubace [3]

Srdeční funkce

• Kardiotonika [3]

Hydratace

Krevní tlak

• Akutně ne hypotenziva
• Pouze u vysoké hypertenze s diastolou nad 220/120-130 mmHg opatrně
• Sledovat tlak
• Jen látky s min. NÚ na CNS perfúzi [3]
• Ebrantil [Dr. Šebek v Benešově]
• Labetalol (Trandate) [3]
• ACEI s krátkým poločasem - Captopril (Capoten) [3]
• Nikdy blokátory kalciových kanálů - Nifedipn (Corinfar) [3]
• Příliš strmý pokles TK
• Také ne diuretika (pouze v případě srdečního selhání) [3]

Tělesná teplota

• Horečku snižovat antipyretiky [3]
• Je lepší blokátor Cox 1 a 2 než paralen ???
• Paralen snižuje antiox. kapacitu jater... a má slabší protizánětlivé účinky... ???

Neklid

• Nepoužívat fenothiaziny ani diazepam [3]

Iontová bilance

Nutrice

• Nutričně definovaná strava nasogastrickou sondou
• častá hyperglykémie v první fázi - nepodává se glukóza
• hyperglykémie zvyšuje rozsah malacie
• Vždy terapie inzulínem s krátkým poločasem účinku [3]

Antitrombotická terapie - protidestičková

• Proti vzniku trombu na ateroskl. plátu a embolizaci
• Co nejdříve
• Zábrana další progrese stavu
• Kyselina acetylsalicylová (Aspirin) 100-400mg /d [3]

Antitrombotická a antikoagulační

• Nízké dávky heparinu 5000 j 2x d
• Nízkomolekulární heparin - fraxiparin 0,3 ml s.c. 1x d
• Vyšší dávky v terapii embolií
• Vyšší riziko hemoragické transformace [3]

Trombolytická terapie

• 75-80% ischemických iktů důsledkem trombembolické okluze
• R-tPA (rekombin. tkáňová aktivátor plazminogenu) - (Actilyse)
• I.v. dle přísných indik. kritérií
• Nutno zahájit do 3h od vzniku iktu
• Riziko intrakr. hemoragie [3]

Protiedémová terapie

• Nejč. 24-48 h po iktu
• Polohování hlavy ve zvýšené poloze min. 30° nad podložku
• Odstranění všech bolestivých podnětů
• Oxygenace řádně
• Normalizace tělesné teploty
• Hypertonický roztok NaCl i.v.
• V těžších příp. mannitol i.v.
• Kortikosteroidy - neprokázán benefit, někde se přesto podávají [3]

Vazoaktivní látky a hemoreologik

• Efekt nebyl prokázán - nepodávají se (někde stále ano) [3]

Profylaxe komplikací

• Bronchopneumonie nejčastější
• Hypoventilace
• Aspirace
• Infekce močových cest
• Trombembolie
• dekubity
• Malhygiena
• Konjunktivitis
• Syndrom zatuhlého ramene [3]

Rehabilitace

• Co nejdříve
• Mobilizace
• Reedukace řeči [3]

Operační terapie

• Endartektomie - A.C.I.
• Po TIA, RIND preventivně
• Ev.po malém iktu
• úplné uzávěry A.C.I.
• Operačně / trombolyticky jen v 1. pár hodinách po iktu
• PTA
• Stenty
• Dekompresivní kraniotomie [3]

Afázie ev. vertigo po CMP

1xd i.v.:

• 500 ml FR
• Oxantil 2 Amp.
• MgSO4 1 Amp.
• Geratam 3g [1]

• Po CMP lze podávat heparinová antikoagulancia v terapeutické dávce pouze 1. 3 dny
• Poté jen dávka preventivní
• Např.: 0,4 ml clexane apod.
• Jinak riziko konverze na hemorhagickou CMP [1]

Zdroje informací:

[1] cmp.cz
[2] web české neurologické společnosti
[3] AMBLER, Zdeněk. Základy neurologie. 6. vydání. Praha : Galén, 2006, vydáno v r. 2007, 352 stran. ISBN 80-7262-433-4.