İnmede Acil Tanı ve Tedavi Yöntemleri
Özet
İnme; iskemik ve hemorajik olmak üzere iki ana sınıfta incelenen, patofizyolojik süreçleri ve tedavi prensipleri farklılık gösteren akut bir nörolojik acildir. Teşhis ve tedavide zaman faktörü kritik öneme sahip olup, kontrastsız bilgisayarlı tomografi (BT) ve difüzyon ağırlıklı manyetik rezonans görüntüleme (MRG) gibi nörogörüntüleme yöntemleri iskemik ve hemorajik inme ayrımını yapmada, ayrıca inme taklitçilerini ekarte etmede temel araçlardır. Akut iskemik inme vakalarında ilk 4,5 saatte intravenöz trombolitik (Alteplaz) tedavisi, ilk 24 saat içinde ise uygun kriterleri sağlayan büyük damar tıkanıklıklarında mekanik trombektomi gibi reperfüzyon stratejileri hayati rol oynar. Serebral venöz trombozda antikoagülasyon tedavisi temel dayanak iken, intraserebral kanamalarda (İSK) agresif kan basıncı yönetimi ve kafa içi basıncını düşürmeye yönelik mannitol kullanımı ile gerektiğinde cerrahi hematom boşaltılması uygulanır. Subaraknoid kanamalarda (SAK) ise anevrizmanın kliplenmesi veya koillenmesi gibi acil girişimlerin yanı sıra yeniden kanama, hidrosefali ve vazospazm gibi major komplikasyonların monitorizasyonu ve yönetimi esastır.
Stroke is an acute neurological emergency classified into two main categories as ischemic and hemorrhagic, each presenting distinct pathophysiological processes and treatment principles. The element of time is highly critical in diagnosis and treatment, where neuroimaging modalities such as non-contrast computed tomography (CT) and diffusion-weighted magnetic resonance imaging (MRI) serve as foundational tools to differentiate between ischemic and hemorrhagic strokes and to rule out stroke mimics. In acute ischemic stroke, reperfusion strategies play a vital role, including intravenous thrombolytic (Alteplase) therapy within the first 4.5 hours and mechanical thrombectomy within the first 24 hours for patients with large vessel occlusions who meet specific eligibility criteria. While anticoagulation therapy remains the mainstay for cerebral venous thrombosis, the management of intracerebral hemorrhage (ICH) relies on aggressive blood pressure control, the use of mannitol to reduce intracranial pressure, and surgical hematom evacuation when indicated. For subarachnoid hemorrhage (SAH), urgent interventions such as surgical clipping or endovascular coiling of the aneurysm are essential, alongside the close monitoring and management of major complications including rebleeding, hydrocephalus, and cerebral vasospasm.
Referanslar
Caplan LR. Basic pathology, anatomy and pathophysiology of stroke. Caplan's stroke: a clinical approach. 2000:34-80.
Carandang R, Seshadri S, Beiser A, et al. Trends in incidence, lifetime risk, severity, and 30-day mortality of stroke over the past 50 years. Jama. 2006;296(24):2939-2946.
Zubair AS, Sheth KN. Emergency Care of Patients with Acute Ischemic Stroke. Neurol Clin. 2021;39(2):391-404.
Lee E-J, Kim Y-H, Kim N, et al. Deep into the brain: artificial intelligence in stroke imaging. Journal of stroke. 2017;19(3):277.
Öge AE, Baykan B, Bilgiç B, Serebrovasküler Hastalıklar, Nöroloji e-ders kitabı, 2020. (05.12.2021 tarihinde http://www.itfnoroloji.org/ekitap.htm)
Adams Jr HP, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. stroke. 1993;24(1):35-41.
Panuganti KK, Tadi P, Lui F. Transient Ischemic Attack. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2021, StatPearls Publishing LLC.; 2021.
Ferro JM, Aguiar de Sousa D. Cerebral Venous Thrombosis: an Update. Curr Neurol Neurosci Rep. 2019;19(10):74.
Bladin CF, Alexandrov AV, Bellavance A, et al. Seizures after stroke: a prospective multicenter study. Archives of neurology. 2000;57(11):1617-1622.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. stroke. 2019;50(12):e344-e418.
Isenegger J, Meier N, Lämmle B, et al. D-dimers predict stroke subtype when assessed early. Cerebrovascular diseases. 2010;29(1):82-86.
Molina CA, Saver JL. Extending reperfusion therapy for acute ischemic stroke: emerging pharmacological, mechanical, and imaging strategies. stroke. 2005;36(10):2311-2320.
Méndez-Gallardo JJ, Méndez B, Cano-Nigenda V, et al. Update on the management of acute stroke. A practical clinical guide. Revista mexicana de neurociencia. 2020;21(4):163-177.
Zerna C, Thomalla G, Campbell BC, et al. Current practice and future directions in the diagnosis and acute treatment of ischaemic stroke. The Lancet. 2018;392(10154):1247-1256.
Wardlaw JM, Seymour J, Cairns J, et al. Immediate computed tomography scanning of acute stroke is cost-effective and improves quality of life. stroke. 2004;35(11):2477-2483.
El-Koussy M, Schroth G, Brekenfeld C, et al. Imaging of acute ischemic stroke. Eur Neurol. 2014;72(5-6):309-316.
Marks MP, Holmgren EB, Fox AJ, et al. Evaluation of early computed tomographic findings in acute ischemic stroke. stroke. 1999;30(2):389-392.
Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: the European Cooperative Acute Stroke Study (ECASS). Jama. 1995;274(13):1017-1025.
Wardlaw J, Dorman P, Lewis S, et al. Can stroke physicians and neuroradiologists identify signs of early cerebral infarction on CT? Journal of Neurology, Neurosurgery & Psychiatry. 1999;67(5):651-653.
Barber PA, Demchuk AM, Zhang J, et al. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. The Lancet. 2000;355(9216):1670-1674.
von Kummer R, Weber J. Brain and vascular imaging in acute ischemic stroke: the potential of computed tomography. Neurology. 1997;49(5 Suppl 4):S52-S55.
Latchaw RE, Alberts MJ, Lev MH, et al. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. stroke. 2009;40(11):3646-3678.
Schellinger P, Bryan R, Caplan L, et al. Evidence-based guideline: the role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2010;75(2):177-185.
Beauchamp Jr NJ, Barker PB, Wang PY, et al. State of the Art-Imaging of Acute Cerebral Ischemia-This State of the Art describes the central role of the radiologist and neuroimaging in the diagnosis and subsequent management of acute. Radiology-Radiological Society of North America. 1999;212(2):307-324.
Sorensen AG, Buonanno FS, Gonzalez RG, et al. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Radiology. 1996;199(2):391-401.
Schlaug G, Siewert B, Benfield A, et al. Time course of the apparent diffusion coefficient (ADC) abnormality in human stroke. Neurology. 1997;49(1):113-119.
Hunsche S, Moseley ME, Stoeter P, et al. Diffusion-tensor MR imaging at 1.5 and 3.0 T: initial observations. Radiology. 2001;221(2):550-556.
Rosso C, Drier A, Lacroix D, et al. Diffusion-weighted MRI in acute stroke within the first 6 hours: 1.5 or 3.0 Tesla? Neurology. 2010;74(24):1946-1953.
Kang D-W, Chalela JA, Dunn W, et al. MRI screening before standard tissue plasminogen activator therapy is feasible and safe. stroke. 2005;36(9):1939-1943.
Ay H, Buonanno F, Rordorf G, et al. Normal diffusion-weighted MRI during stroke-like deficits. Neurology. 1999;52(9):1784-1784.
Patel MR, Edelman RR, Warach S. Detection of hyperacute primary intraparenchymal hemorrhage by magnetic resonance imaging. stroke. 1996;27(12):2321-2324.
Kidwell CS, Chalela JA, Saver JL, et al. Comparison of MRI and CT for detection of acute intracerebral hemorrhage. Jama. 2004;292(15):1823-1830.
Schramm P, Schellinger PD, Klotz E, et al. Comparison of perfusion computed tomography and computed tomography angiography source images with perfusion-weighted imaging and diffusion-weighted imaging in patients with acute stroke of less than 6 hours’ duration. stroke. 2004;35(7):1652-1658.
Albers GW, Marks MP, Kemp S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. New England Journal of Medicine. 2018;378(8):708-718.
Chalela JA, Alsop DC, Gonzalez-Atavales JB, et al. Magnetic resonance perfusion imaging in acute ischemic stroke using continuous arterial spin labeling. stroke. 2000;31(3):680-687.
Johnston DC, Chapman KM, Goldstein LB. Low rate of complications of cerebral angiography in routine clinical practice. Neurology. 2001;57(11):2012-2014.
Kaufmann TJ, Huston III J, Mandrekar JN, et al. Complications of diagnostic cerebral angiography: evaluation of 19 826 consecutive patients. Radiology. 2007;243(3):812-819.
Silva GS, Nogueira RG. Endovascular Treatment of Acute Ischemic Stroke. Continuum (Minneap Minn). 2020;26(2):310-331.
Rabinstein AA. Update on Treatment of Acute Ischemic Stroke. Continuum (Minneap Minn). 2020;26(2):268-286.
Kurian C, Kaur K, Kaur G, et al. Assessment of the Patient With Intracerebral Hemorrhage: A Review of the Literature. Cardiol Rev. 2021;29(1):20-25.
Rajashekar D, Liang JW. Intracerebral Hemorrhage. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2021, StatPearls Publishing LLC.; 2021.
Kobata H, Ikeda N. Recent Updates in Neurosurgical Interventions for Spontaneous Intracerebral Hemorrhage: Minimally Invasive Surgery to Improve Surgical Performance. Front Neurol. 2021;12:703189.
Ziu E, Mesfin FB. Subarachnoid Hemorrhage. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2021, StatPearls Publishing LLC.; 2021.
Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. Handb Clin Neurol. 2021;176:135-169.
Juif PE, Dingemanse J, Ufer M. Clinical Pharmacology of Clazosentan, a Selective Endothelin A Receptor Antagonist for the Prevention and Treatment of aSAH-Related Cerebral Vasospasm. Front Pharmacol. 2020;11:628956.
Chen S, Luo J, Reis C, et al. Hydrocephalus after Subarachnoid Hemorrhage: Pathophysiology, Diagnosis, and Treatment. 2017;2017:8584753.
