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anevrizmuli subaraqnoiduli sisxlCaqceva: diagnostikis algoriTmi da marTvis principbi

anevrizmuli subaraqnoiduli sisxlCaqceva: diagnostikis algoriTmi da marTvis principbi. aleqsandre ciskariZe Tsu nevrologiisa da neiroqirurgiis departamenti. anevrizmuli subaraqnoiduli sisxlCaqceva. insidensi (sixSire) aSS da evropa – 10-11 SemTxveva 100 000 populaciaze weliwadSi

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anevrizmuli subaraqnoiduli sisxlCaqceva: diagnostikis algoriTmi da marTvis principbi

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  1. anevrizmuli subaraqnoiduli sisxlCaqceva: diagnostikis algoriTmi da marTvis principbi aleqsandre ciskariZe Tsu nevrologiisa da neiroqirurgiis departamenti

  2. anevrizmuli subaraqnoiduli sisxlCaqceva insidensi (sixSire) • aSS da evropa – 10-11 SemTxveva 100 000 populaciaze weliwadSi • saqarTvelo – 16 SemTxveva 100 000 populaciaze weliwadSi • insidensi asakTan erTad (piki me-6 dekada) • 40 wlis Semdeg prevalireba qalebSi

  3. anevrizmuli subaraqnoiduli sisxlCaqceva sikvdiloba: • pirvel dRes – 28% • pirvel kviras – 33% • pirvel Tves – 40% • 6 Tveze – 52%

  4. 30-dRiani sikvdiloba (case-fatality) insultis qvetipebis mixedviT asak- da sqes-standartizebuli maCvenebeblebi: 35.6% (95%CI 29.3-42.2)- msoflios populaciis mimarT 37.4% (95%CI 32.1-42.7)- evropuli populaciis mimarT

  5. inicialuri klinikuri niSnebi • uecari, uZlieresi, “mexis dacemis msgavsi” Tavis tkivili (thunderclap headache) • gulisreva/Rebineba • gulyrebi (10%) – maRali specifikuroba • cnobierebis daTrgunva – SemTxvevaTa 2/3, (maTgan 50% - koma) • kisris rigidoba (3-12 sT)

  6. inicialuri klinikuri niSnebi naklebad tipiuri • fokaluri nevrologiuri deficiti – hematoma (intracerebruli/subduruli), mwvave iSemia (vazokonsriqcia) • III wy. nervis parezi – SigniTa saZile an ukana SemaerTebeli arteriis anevrizma • VI wy. nervis parezi (araspecifikuri niSani) • ekg cvlilebebi (miokardiumis iSemiis mimikria, gulis gaCereba – SemTxvevaTa 3%-Si)

  7. Thunderclap headache-is sxva mizezebi • cerebruli venuri sinusebis Trombozi • kisris arteriebis (saZile, vertebruli) gaSreveba • spontanuri intrakraniuli hipotenzia • hipofizuri apopleqsia • iSemiuri insulti • mwvave hipertonuli krizi • gardamavali cerebruli vazokonstriqciuli sindromo • III parkuWis koloiduri kista • intrakraniuli infeqcia • pirveladi Thunderclap headache • pirveladi daZabvis, xvelis, koitusis Tavis tkivili

  8. gamokvlevebi • kompiuteruli tomografia (sensitioba >95% pirvel dRes, Semdgom ) • Tavzurtvinis siTxis gamokvleva (Cveneba – uecari, Zlieri Tavis tkivili, negatiuri CT) • fundoskopia • magnitur-rezonansuli tomografia (mogvianebiT stadiebSi) • angiografia (digitalur-subtraqciuli, CT, MRI)

  9. kompiuteruli tomografia

  10. kompiuteruli tomografia

  11. kompiuteruli tomografialobaluri hemoragia - anevrizmuli subaraqnoidul-pareqimuli sixlCaqceva

  12. kompiuteruli tomografia III dRe I dRe

  13. fsevdosubaraqnoiduli sisxlCaqceva(tvinis difuzuri SeSupeba)

  14. qsantoqromia siTxis speqtrofotometria saeWvo SemTxvevebSi!

  15. subhialoiduri (periretinuri) da vitreuli hemoragia (tersonis sindromi)

  16. CT vs MRI 0-48 sT 7 dRe

  17. CT vs MRI me - 4 dRe, CT negatiuri, MRI – T2*

  18. cerebruli anevrizmebis lokalizacia tvinis Sua art. wina SemaerTebeli art. ukana Semaer- Tebeli art. baziluri arteria naTxemis qvemo ukana arteria

  19. angiografia wina SemaerTebeli arteriis anevrizma

  20. angiografia tvinis Sua arteriis anevrizma baziluri arteriis anevrizma

  21. araanerizmululi subaraqnoiduli sisxlCaqcevis mizezebi (iSviaTi) cerebruli arteriebis anTebiTi daavadeba • mikozuri (septikuri) anevrizmebi • boreliozi • behCetis daavadeba • pirveladi angiiti • Carj-strausis daavadeba • vegeneris granulomatozia • kvanZovani poliarteriiti intracarebruli sisxlZarRvebis araanTebiTo dazianeba • arteriis ganSreveba • artetriovenuri malformacia • fuziformuli anevrizma • duraluri fistula • kavernomuli angioma • cerebruli venuti Trombozi • cerebruli amiloiduri angiopaTia • moiamoias daavadeba

  22. araanerizmululi subaraqnoiduli sisxlCaqcevis mizezebi (iSviaTi) zurgis tvinis sisxlZarRvovani daavadeba • spinaluri arteriis parkisebri anevrizma • spinaluri arteriovenuri fistula an malformacia • spinaluri kavernuli angioma simsivneebi • pituituri (hipofizuri) apopleqsia • kardiuli miqsomis cerebruli metastazebi • avTvisebiani glioma • akustikuri nevrinoma • angiolipoma • kraniuli nervis Svanoma • kisris midamos meningioma • zurgis tvinis kisris donis hemangioblastoma • spinaluri meningealuri karcinomatozi • raSis kudis melanoma medikamentebi • antikoagulantebi • kokaini Talasemia, koagulopTiebi

  23. Thunderclap headache-is diagnostikuri algoriTmi

  24. subaraqnoiduli sisxlCaqcevis diagnostikuri algoriTmi

  25. anevrizmuli subaraqnoiduli sisxlCaqceva garTulebebi: • rehemoragia • hidrocefalia • mogvianebiTi iSemia (vazospazmi) • gulyrebi • sistemuri garTulebebi (hiponatremia, ariTmia, hipotenzia, infeqcia, filtvebis neirogenuli SeSupeba, pnevmonia)

  26. rehemoragia • kumulaciuri riski 40% (intervenciis gareSe) • maRali sikvdiloba da invalidizacia (80%) • prevencia – anevrizmis klipireba (Ria neiroqirurgiuli operacia) an endovaskuluri intervencia (coiling) • intervenciis optimaluri dro – 0-78 sT (idealuri 0-24 sT)

  27. anevrizmis klipireba

  28. anevrizmis klipireba

  29. endovaskuluri intervencia (coiling)

  30. endovaskuluri intervencia (coiling)

  31. hidrocefalia • SemTxvevaTa 25% • korelirebs sisxlCaqcevis intensivobasTan • cnobierebis TandaTanobiTi daqveiTeba pirveli 24 saaTis ganmavlobaSi • zogjer – Tvalebis deviacia qvemoT, viwro gugebi • diagnostika – seriuli CT • marTva - mocda da dakvirveba (spontanuri ukuganviTareba) - seriuli lumbaluri punqciebi - ventrikuluri drenaJi/stoma (infeqciis maRali riski)

  32. hidrocefalia (seriuli LP)

  33. mogvianebiTi iSemia (vazospazmi) • SemTxvevaTa 1/3-Si • sikvdilobis mizezi 14%-Si • ganviTarebis piki me-5 dan me-14 dRemde • korelirebs subaraqnoidul sivrceSi sisxlis raodenobasTan • kompleqsuri paTogenezi - vazospazmi (angiografiulad 70%-Si) - angiopaTia (endoTeliuri disfunqcia, intimis proliferacia, mediis SeSupeba, fibrozi, nekrozi) - intrakraniuli hipertenzia, dehidratacia, hipotenzia, hipovolemia, hiperglikemia, gulyrebi

  34. mogvianebiTi iSemia (vazospazmi)

  35. mogvianebiTi iSemiis profilaqtika/mkurnaloba • anevrizmis adreuli klipireba • kalciumis antagonistebi (nimotopi) • Triple H Terapia - hemodilucia/hidratacia (hiponatremiis prevencia/mkurnaloba) - hipervolemia - marTviTi hipertenzia

  36. nimotopi (hemodinamikuri efeqtebi) • tropizmi koronaruli da cerebruli sisxlZarRvebis (gansakuTrebiT intrakraniuli) gluvi kunTebebis mimarT • pirdapiri vazodilataciuri efeqti • Tavis tvinis lokaluri sisxlnakadis gazrda (39-84%) metabolizmis gaZlierebis efeqtis gareSe • K+, prostaglandin 2, noradrenaliniT da serotononiT inducirebuli kunTovani SekumSvis (kontraqtilobis) Semcireba

  37. nimotopi (neiroproteqciuli efeqtebi) • globaluri iSemiis modeli placebosTan SedarebiT: - nevrologiuri gamosavlis gaumjobeseba - eeg aqtiobis gamosworeba - ATP-is donis momateba - glukozis metabolizmis gamosworeba • fokaluri iSemiis modeli placebosTan SedarebiT: - lokaluri sisxlnakadis naklebad daqveiTeba - nevrologiuri gamosavlis gaumjobeseba - infarqtis keris Semcireba - intraceluluri PH-is momateba

  38. nimotopi (klinikuri efeqtebi) Cochrane Collaboration –is metaanalizi subaraqnoiduli sisxlCaqcevis dros kalciumis antagonistebis efeqturobis Sesaxeb (2006) • 11 kvleva (2804 pacienti, 1376 - aqtiuri Terapia, 1428 - placebo) Sefasebis kriteriumi - arasasurveli gamosavali (GOS) SedarebiTi riski (RR) 0.82 (95% CI 0.72 – 0.93) absoluturi riskis Semcireba – 5.1% NNT - 20 • nimodipini (8 kvleva, 1574 pacienti) RR 0.69 (95% CI 0.58 – 0.84)

  39. nimotopi (klinikuri efeqtebi) Cochrane Collaboration –is metaanalizi subaraqnoiduli sisxlCaqcevis dros kalciumis antagonistebis efeqturobis Sesaxeb (2006) • eqspertTa panelis daskvna: anevrizmuli subaraqnoiduli sisxlCaqcevis dros kalciumis antagonistebi amcirebs cudi gamosavlis da iSemiuri nevrologiuri deficitis mqone pacientTa proporcias. peroraluri nimodipinis efeqti aRemateba yvela sxva kalciumis antagonistis efeqts. amitom nimodipini (60 mg 4 sT-Si erTxel per os) rekomendirebulia rutinuli xmarebisaTvis anevrizmuli subaraqnoiduli sisxlCaqcevis mqone pacientebSi

  40. rom SevajamoT... • anevrizmuli subaraqnoiduli sisxlCaqceva cerebrovaskulur katastrofebs Soris erT-erTi umniSvnelovanesia • miuxedavad Tanamedrove diagnostikuri da samkurnalo teqnologiebis ganviTarebisa, problebad rCeba daavadebis maRali sikvdiloba da morbidoba • daavadebis adreuli da swori diagnostika adeqvaturi mkurnalobis meTodebis gamoyenebasTan erTad saSualebas iZleva daavadebis samedicino da socialuri tvirTis mniSvnelovani Sebsubuqebis

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