|
#76
28.02.2010, 18:45
|
|||
|
|||
|
Только нативное КТ. Мы делали двум больным МР-перфузию и одному больному КТ-ангиографию - картинки получились красивые, но в общем это была необоснованная трата ресурсов и главное времени.
|
|
#79
28.02.2010, 19:50
|
|||
|
|||
|
Там было просто стечение обстоятельств - дело было в выходной день, компьютерный томограф почему-то не запустился. Чтобы не терять времени решили сделать МР-перфузию (МРТ-аппарат, по счастью, в этот день работал - принимали амбулаторных больных).
Насколько я себе представляю, основная цель визуализации в данном случае - исключить геморраж. Диагностика проводится преимущественно клинически. Но меня смущает в этом деле один момент. Согласно внутреннему протоколу тромболизиса, процедура противопоказана если имеются "ранние признаки ишемических изменений на данным КТ более 1/3 полушария" - интересно, имеется в виду нативное КТ или методы исследования перфузии ? У нас в одном из двух случаев когда мы делали МР-перфузию - зона гипоперфузии была значительно больше трети полушария (зона отсутсвующего кровотока - значительно меньше) - не являлось ли это противопоказанием для тромболизиса ? Мы решили что нет. Тромболизис прошел без осложнений, эфект - не драматический - но отмечался.
|
|
#80
28.02.2010, 20:03
|
|||
|
|||
|
Возможно, будет интересно:
SAN ANTONIO -- Because many strokes occur when the patient is alone, with no one to verify when it began, recombinant tissue-plasminogen activator (tPA) -- approved for use within three hours of stroke onset -- is often withheld. But the lack of a witness is not an insurmountable barrier, according to Demetrios J. Sahlas, MD, of McMaster University in Hamilton, Ontario. Sahlas and colleagues compared outcomes of 1,082 patients who received tPA to treat "witnessed strokes" to outcomes in 480 patients who received tPA following "unwitnessed" strokes and discovered only one significant difference: Those whose strokes were witnessed were more likely to hemorrhage (OR 1.62, 95% CI 1.10 to 2.38). In the retrospective study reported at the American Stroke Association's International Stroke Conference, 7.9% of patients with unwitnessed strokes versus 12.1% of patients with witnessed strokes developed hemorrhages. "About a third of ischemic stroke patients treated with tPA had unwitnessed strokes," Sahlas said. The patients were treated from 2003 through 2008 at 11 stroke centers in Ontario. A little over half of patients were men and in general men were slightly younger than women (72 versus 75). Sahlas said patients qualified for tPA based on the time the patients "were last seen normal," typically three hours before they were found with stroke symptoms. Using that three hour window for "last seen normal" and adding "an estimated 60 minutes from door to needle to administer tPA, we would be administering the drug within the 4.5-hour window," Sahlas told MedPage Today. The FDA has approved tPA for use within the first three hours after stroke onset, but a 2009 science advisory from the American Heart Association/American Stroke Association recommends extending the treatment window to 4.5 hours for certain patients. Lee H. Schwamm, MD, of Massachusetts General Hospital, told MedPage Today that the findings from the Canadian group were not surprising because "by using 'last seen normal,' you have a group that is likely to include those whose stroke onset was less than three hours, which would enrich the results." For example, someone who last seemed normal at 3 p.m., might have experienced a stroke at 5:30 p.m. and have been discovered at 6 p.m., so the stroke onset would have been only 30 minutes prior to discovery. By the same token, Sahlas said, the patient might have experienced a stroke "one minute after they were last seen as normal." For that reason, he said he would not feel comfortable using tPA in a patient who was last seen normal four and half hours earlier. "But," he said, "I would recommend tPA for a patient last seen normal three to three and half hours earlier." Although tPA has been recommended since it was approved by the FDA in 1996, the use of the drug has lagged -- often because of concerns about bleeding risk. Schwamm said tPA use has been "increasing incrementally and steadily" in recent years but when asked if it was being used to treat at least 10% of eligible stroke patients, he said he couldn't confirm that rate. He did say, however, that among some 1,600 stroke centers that participate in the AHA/ASA "Get with the Guidelines" program, there were data indicating that "60% of tPA-eligible patients treated at those centers are receiving the drug." Sahlas noted that the study was limited by the use of retrospective registry data. Moreover, he pointed out, "we have a single healthcare system, so the results might not be generalizable in other settings." Primary source: American Stroke Association Source reference: Sahlas DJ, et al "24 acute stroke patients treated with IV tPA based on "time last seen normal" have lower rates of hemorrhagic transformation than patients with a witnessed symptom onset" ASA 2010; Abstract 24. February 25, 2010
|
|
#82
28.02.2010, 20:14
|
||||
|
||||
|
Цитата:
 и это непреодолимая проблема...
|
|
#83
28.02.2010, 20:18
|
||||
|
||||
|
Efficacy Of CT Perfusion In Diagnosis Of Acute Ischemic Stroke Demonstrated By WVU :
A study conducted by a team of stroke experts from West Virginia University Health Sciences Center demonstrates that CT (computed tomography) perfusion imaging - a technology which measures blood flow and is available to most hospitals - may dramatically improve fast and accurate stroke diagnosis, enabling physicians to provide more targeted care and helping avoid potentially life-threatening complications of "clot buster" therapy. The WVU study is the largest to date of the lifesaving technology's utility in diagnosing stroke and staging its treatment. The study, published in the October 2008 issue of The Journal of Emergency Medicine, shows that using CT perfusion to diagnose stroke may be as valuable as magnetic resonance imaging (MRI) - an imaging technology that takes far longer to use at a time when every second counts before treatment is initiated. The CT technology allows physicians to identify patients who are suitable candidates for treatment, utilizing either clot busting medicines or clot retrieval devices. WVU researchers believe this research could change national protocols on how stroke patients are triaged and potentially extend treatment opportunity beyond the three-to-six hour window. "Our study reveals that the widespread use of CT perfusion is a practical way to help busy emergency departments save precious time in stroke diagnosis, target treatment and reduce the risks of inappropriate thrombolytic use," said Ansaar T. Rai, MD, Assistant Professor of Neuro Radiology & Neurointerventional Radiology. "CT perfusion was able to pinpoint strokes with high levels of accuracy, particularly the major intracranial vessel strokes that result in more devastating outcomes." Key findings of the study include: CT perfusion has a very high sensitivity rate - 92% - for detecting infarcts due to a major vessel occlusion, the most debilitating kind of stroke. The specificity rate for detecting acute ischemic stroke was perfect - 100%. The researchers, who have used CT perfusion in clinical practice with the largest reported number of suspected stroke victims of any center in the U.S., also report that the average time between emergency room neurological exam and CT scan was 35 minutes. Under National Institutes of Health guidelines, hospitals should administer tPA (a clot-busting, or thrombolytic, drug) to patients within a three-hour window of stroke onset. After six hours, the medicine is considered too risky, due to the possibility of a deadly hemorrhage. Just one to two percent of stroke patients receive clot busters. Experts believe this is due largely to perceived risks and uncertainty about whether patients are actually having strokes. A fast, accurate and accessible means of diagnosis of could change these statistics. To determine CT perfusion's utility, Rai and colleagues conducted a retrospective analysis with 867 patients who underwent CT perfusion as part of a routine evaluation for suspected stroke at WVU's Ruby Memorial Hospital. Only patients who had a follow up MRI scan within one week - 422 - were included in the analysis. CTP abnormalities in these patients were compared with subsequent diffused weighted image (DWI) abnormalities seen on follow up MRI scans. Magnetic resonance imaging tests (MRIs) are considered the gold standard for post-stroke analysis, but they are rarely performed and generally impractical because: they take 30 minutes to perform, require a stroke patient to be still to capture clean images, require doctors to check for metal in the patient's body (which may be impossible if the patient is not verbal) and the MRI units themselves are often understaffed or not located near the emergency room. CT perfusion offers distinct advantages because most hospital emergency rooms use CT scanners for other purposes, they take one to two minutes to scan, and provide clear images even if a patient cannot lie perfectly still. Most hospitals need only to buy software (at a relatively low cost) to upgrade their systems and institute training programs. In addition, CT angiograms are necessary to locate blockages - and these can be done simultaneously with the perfusion CT, saving valuable time. With the publication of this study, WVU is leading a high tech effort to integrate care across multiple practice locations and make use of its collection of stroke brain scans, which is one of the largest in medicine. The study findings may have the greatest effect on rural care, but also will help crowded urban centers utilize resources to improve diagnostic times and extend the life of imaging equipment. In addition, the study shows that a hospital and emergency department where comprehensive services are available can potentially serve as the nexus of a "tele-stroke network" in triaging patients and increasing outcomes.
|
|
#84
28.02.2010, 20:51
|
|||
|
|||
|
Цитата:
15 минут от приёмного покоя до процедуры, о чём Вы пишете, время хорошее. А учитываете ли время от начала заболевания? И ещё, при каком АД вводите альтеплазу, корригируете ли его перед введением - на это ведь тоже нужно время. Мне не приходилось работать с этим препаратом, другими тромболитиками работать при инсультах опасались, да и положительной информации не попадалось. Может статься, я поэтому так скептически и отношусь к данному лечению. Следите ли за выписанными после тромболизиса? Если "да", как долго живут? Простите, если очень много вопросов сразу. С уважением, Я.
|
|
#85
28.02.2010, 21:28
|
|||
|
|||
|
Цитата:
Цитата:
|
|
#86
01.03.2010, 07:37
|
|||
|
|||
|
Цитата:
По протоколу, тромболизис можно проводить если АД находится в рамках 185/135 мм рт ст Обычно во время процедуры лично я стараюсь поддерживать систолическое АД у пациентов в рамках 140 - 150 мм рт ст. Пациентов после тромболизиса лично я не отслеживаю. Я - реаниматолог их обычно наблюдаю только первые сутки, дальше до выписки их ведут в неврологическом отделении, и в дальнейшем они наблюдаются амбулаторно. Вот здесь, можно скачать переведенные на русский Европейские рекомендации по ведению инсульта 2008 года: http://www.sendspace.com/file/pg2l5t Там все очень подробно разъясняется. В том числе и моменты связанные с нейровизуализацией.
|
|
#87
01.03.2010, 13:54
|
|||
|
|||
|
Цитата:
Пользуясь Вашим вниманием к моей скромной особе, позволю себе спросить Вас. Чем отличается ответная реакция организма на инсульт и пневмонию. Заранее Вам благодарен. С уважением, Я.
|
|
#88
01.03.2010, 14:09
|
|||
|
|||
|
Цитата:
Цитата:
Цитата:
Я буду внимательно следить за этой темой, нацелю на неё своих бывших коллег, но самому позвольте всё-таки остаться с прежним мнением - это не тот путь. Чудодейственных препаратов не было и не будет. Искренне желаю Вам всяческих успехов. С уважением, Я.
|
|
#89
01.03.2010, 14:33
|
|||
|
|||
|
Цитата:
Цитата:
|
|
#90
01.03.2010, 17:19
|
|||
|
|||
|
Stroke Therapy and Thrombolysis
Stroke Rapid Reference · Emergent Procedure, Requires Immediate Attention · Treat SBP >185 or DBP>110 to reduce risk ICH · Maintain blood pressure SBP>160 mmHG for adequate CPP during procedure · Following successful lysis maintain SBP <150 mmHG to reduce risk ICH or Reperfusion edema · In the Event of ICH after TPA 6 to 8 units platelets, 4 to 6 units Cryoprecipitate, Recombinant Factor VIIa 40to 60mcg/kg Stroke intervention should be considered an emergent procedure, and all effort should be made to start the procedure immediately. The therapeutic window is limited to 6 hours after onset of stroke symptoms. Data suggests earlier treatment within this time window improves outcomes. The patients who have the greatest benefit from this procedure will include patients with a moderate NIH stroke scale score who have symptoms of a large vessel stroke. This mean many of these patients may have symptoms of hemiplegia, facial droop, dysarthria, and receptive and expressive aphasia. The PROCT study suggests a patient treated in a timely fashion will be 2.5 times more likely to live independently at 90 days post discharge compared to controls. The following recommendations are made based on American Stroke Association Guidelines and Guidelines from the CCF Stroke Center. These patients should have labs drawn on arrival in the ED, including CBC, Chemistries, and PT, PTT or should have labs from the transfer hospital. A 12 lead EKG should be present as ventricular arrhythmias, new onset atrial fibrillation, and myocardial infarction are highly associated with stroke and may impact your medical decision making. It is not unreasonable to ask for these tests before anesthetizing the patient. The ED physician will have screened the patient with a t-PA screening protocol check sheet before the patient becomes a candidate. At this institution general endotracheal anesthesia is commonly used during intra-arterial thrombolysis. Although level 1 evidence for supportive care in stroke patients is lacking, animal models support elevating cerebral perfusion pressures to maintain collateral perfusion of the ischemic brain penumbra. The American stroke association (ASA) does not recommend the treatment of blood pressures above the level of SBP of 180 or DBP of 110 in patients receiving thrombolytic therapy. BP above these levels is associated with increased risk of intracranial hemorrhage post thrombolysis and is a contraindication to therapy if it cannot be lowered before treatment. The blood pressure should be treated gingerly. Current recommendations from the ASA and the CC stroke center suggest the use of labetalol, 10mg bolus, to a 150 mg maximum dose. If the patient requires additional medications a nitroprusside infusion starting at 0.5 to 1 mcg/kg/min has also been recommended. The agent selected is at the discretion of the anesthesiologist. Obviously, one must take into consideration the need to maintain cerebral perfusion pressure during induction and the labile arterial blood pressures which can occur in critically ill patients under general anesthesia. The exact goal for BP management is not known. A general recommendation is to maintain a SBP of 160 or above. Goals for glucose management include avoiding hyperglycemia as it has an associative link to poor outcomes in stroke. Again, good data is lacking for a causative link. The ASA and CC guidelines are to avoid glucose containing fluids. Glucose >200 mg/dl has been suggested as a trigger for glucose treatment in stroke patients. Glucose > 200 mg/dl has also been associated with increased risk of ICH. The starting of insulin infusions for glucose control is at the discretion of the anesthesiologist. One should use caution, as the several studies have demonstrated a high percentage of hypoglycemia in stroke patients treated with aggressive insulin therapy for normalization of glucose. Following successful thrombolysis, the recently ischemic brain tissue is at risk for reperfusion injury in the form of tissue edema or intracranial hemorrhage. The pathophysiology of reperfusion edema and hemorrhage has been suggested to be a loss of autoregulation in the cerebral vessels distal to the location of the thrombotic vessels. The distal vessels in the area of the ischemic brain may remain vasodilated despite the return of normal perfusion pressures. Tissue edema and bleeding may occur because of the increased and unregulated local perfusion pressure and hydrostatic pressures. Again a specific target goal for postprocedural BP is not known. The general recommendation would be a SBP < 150 mmHg. In the event of life threatening hemorrhage in a patient treated with TPA, administer 6 to 8 units of platelets and 4 to 6 units of cryoprecipitate. Recombinant factor VIIa 40 to 60 mcg/kg may also be given to reduce bleeding. · Exclusion Criteria · SBP>185, DBP>110 · Rapidly improving symptoms · Seizure at onset · Stroke within 3 mo · Head trauma within 3 mo · GI, GU hemorrhage within 21 days · Arterial Puncture at noncompressive site within 7 days · Patient on anticoagulants or heparin within 48 hours · PT greater than 15 · Platelet Count <100, 000 · Glucose <50 · Glucose >400 Это наш местный анестезиологический протокол для ведения пациентов с ишемическим инсультом для интрартериального тромболизиса (2006 года - я лично последний раз смотрела литературу по теме года полтора назад, но тогда ничего нового не было). Уважаемый remember, а в чём Вы лично видите "тот путь"? Просто любопытно  .
|
Линейный вид
