{"id":5116,"date":"2015-12-18T11:01:08","date_gmt":"2015-12-18T11:01:08","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=5116"},"modified":"2016-01-20T12:00:12","modified_gmt":"2016-01-20T12:00:12","slug":"penumbra-ischemica-in-avc","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/penumbra-ischemica-in-avc\/","title":{"rendered":"Penumbra ischemic\u0103 \u00een AVC"},"content":{"rendered":"

Rolul neuroimagisticii \u00een evaluarea pacien\u021bilor cu AVC hiperacut a crescut odat\u0103 cu dezvoltarea terapiilor trombolitice. Dac\u0103 pentru o lung\u0103 perioad\u0103, rolul imagisticii a fost doar unul de excludere a leziunilor care mimeaz\u0103 AVC ischemic,\u00a0 ast\u0103zi tomografia computerizat\u0103 \u0219i rezonan\u021ba magnetic\u0103\u00a0 ofer\u0103 metode performante \u00een determinarea cauzelor infarctului, \u00een identificarea zonelor de penumbr\u0103 ischemic\u0103, \u00een triajul pacien\u021bilor pentru terapia trombolitic\u0103 \u0219i \u00een monitorizarea evolu\u021biei terapeutice.<\/p>\n

Rolul perfuziei (PWI) CT \u0219i IRM\u00a0 \u00een stroke const\u0103 \u00een identificarea nucleul infarctat (cu valori ale volumului cerebral sanguin extrem de sc\u0103zute), \u00een triajul pacien\u021bilor pentru terapia trombolitic\u0103 (la debutul unui AVC, prezen\u021ba unei zone de penumbr\u0103 opera\u021bional\u0103 cu risc de infarctizare\u00a0 reprezint\u0103 o indica\u021bie c\u0103 terapia trombolitic\u0103 poate fi benefic\u0103) sau pentru celelalte terapii disponibile, precum \u201ehipertensiune indus\u0103\u201c, hipotermia etc, \u00een excluderea condi\u021biilor care mimeaz\u0103 stroke-ul \u0219i \u00een monitorizarea pacien\u021bilor afla\u021bi sub terapie.<\/em><\/p>\n

Delimitarea zonei de penumbr\u0103 ischemic\u0103<\/strong> (\u021besut cu risc de infarctare, posibil recuperabil prin instituirea terapiei trombolitice) este dat\u0103 \u00een IRM de ,,mismatch\u201d- ul dintre fuziunea extinderii DWI (difuzie) \u0219i cea a PWI (perfuzie) \u0219i \u00een CT de \u201emismatch\u201d-ul dintre imaginile surs\u0103 din angiografia CT \u0219i perfuzia CT.<\/p>\n

Penumbra ischemic\u0103 \u00een CT \u2013 mismatch CBV\/CBF \u0219i CBV\/CTA-SI<\/strong><\/p>\n

Protocolul CT \u00een AVC: CT nativ, perfuzie (CTP), angiografie CT (CTA)<\/p>\n

Perfuzia CT<\/strong> aduce indicii asupra func\u021biei cerebrale prin m\u0103surarea unor parametri hemodinamici la nivelul microcircula\u021biei \u0219i asupra parenchimului cerebral \u0219i permite diferen\u0163ierea ariilor ischemice, care sunt supuse riscului de infarctizare, de ariile de infarctizare real\u0103. CTP arat\u0103 tipul, v\u00e2rsta \u0219i extinderea procesului ischemic \u00een AVC.<\/p>\n

\u00cen imagistica de perfuzie CT se ob\u0163in o serie de imagini ale teritoriilor arterelor cerebrale medii dup\u0103 administrarea i.v.<\/em> a substan\u0163ei de contrast, iar modific\u0103rile de atenuare (priza de contrast) a parenchimului cerebral se m\u0103soar\u0103 \u00een timp.<\/p>\n

Perfuzia CT permite calcularea unor parametrii esen\u021biali pentru diferen\u021bierea nucleului de penumbra ischemic\u0103, precum:<\/p>\n

– TTP <\/strong>( timp de \u00eenc\u0103rcare maxim\u0103) – indic\u0103 timpul necesar pentru ca agentul de contrast s\u0103 ating\u0103 \u00eenc\u0103rcarea maxim\u0103 \u00een volumul cerebral de interes);<\/p>\n

– MTT<\/strong> (timpul mediu de tranzit) – timpul pe care o particul\u0103 dat\u0103 (agent de contrast exogen sau endogen) \u00eel petrece \u00een circula\u021bia capilar\u0103 cerebral\u0103;<\/p>\n

– CBV<\/strong> (volum sangvin cerebral) – este o m\u0103sur\u0103 relativ\u0103 a volumului sanguin de la nivelul capilarelor venoase \u0219i arteriale dintr-o regiune de parenchim cerebral; arat\u0103 aria de ischemie constituit\u0103.<\/strong><\/p>\n

– CBF<\/strong> (debit sanguin cerebral) \u2013 care se calculeaz\u0103 prin raportul dintre volumul sangvin \u0219i timpul mediu de tranzit; arat\u0103 aria de ischemie constituit\u0103 \u0219i aria de penumbr\u0103.<\/strong><\/p>\n

Zona de penumbr\u0103 ischemic\u0103 prezint\u0103 TTP sau MTT\u00a0 crescute \u0219i CBV normal sau u\u0219or sc\u0103zut, \u00een timp ce nucleul infarctat (core) are TTP sau MTT\u00a0 crescute \u0219i CBV marcant sc\u0103zut.<\/p>\n\n\n\n\n\n
CBV = CBF<\/td>\ntratament trombolitic exclus<\/td>\n<\/tr>\n
CBV mare <\u00a0 CBF extins<\/td>\nDecizia terapeutic\u0103 dependent\u0103 de timpul post-ictus<\/td>\n<\/tr>\n
CBV mic < CBF extins<\/td>\ncandidat optim pentru terapia trombolitic\u0103<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Mismatch-ul dat de CBV\/ CTA \u2013SI <\/strong>( imaginile surs\u0103 din angiografia CT) – este comparabil cu mismatch-ul dintre DWI\/PWI \u00een IRM. Regiunile hipodense de pe imaginile CTA-SI reflect\u0103 reducerea de volum sangvin (CBV) \u00e0 nucleul infarctului (\u021besut irecuperabil).<\/p>\n

Avantaje CTA-SI<\/strong>: acoper\u0103 \u00eentregul volum cerebral (CTP este limitat de grosimea slice-ului), ofer\u0103 estimare calitativ\u0103 \u0219i cantitativ\u0103 (h\u0103r\u021bi cantitative ale CBV)<\/u>, nu necesit\u0103 post-procesare, informa\u021biile sunt disponibile imediat dup\u0103 scanare.<\/p>\n

Penumbra ischemic\u0103 \u00een IRM: mismatch DWI\/PWI <\/strong><\/p>\n

Protocolul IRM \u00een stroke: (<\/strong>CT nativ), FLAIR- T2: pentru eviden\u021bierea\/excluderea leziunilor vasculare cronice \u0219i a altor anormalit\u0103\u021bi parenchimatoase, DWI:cea mai senzitiv\u0103 \u0219i specific\u0103 tehnic\u0103 capabil\u0103 s\u0103 detecteze\u00a0 infarctul hiperacut, SWI\/ T2EG: pentru excluderea hemoragiei intracerebrale; MRA- pentru determinarea etiologiei stroke-ului \u0219i a dinamicii circula\u021biei vasculare , PWI \u2013 \u00een combina\u021bie cu DWI, diferen\u021biaz\u0103 \u021besutul infarctat ireversibil de cel recuperabil.<\/p>\n

Timp achizi\u021bie: 15-20 min.<\/p>\n

Difuzia (DWI):<\/strong> \u00een edemul citotoxic, apa se acumuleaz\u0103 \u00een celul\u0103, determin\u00e2nd sc\u0103derea coeficientului aparent de difuziune. Este util\u0103\u00a0 \u00een detec\u0163ia zonelor de infarctizare din primele ore de la producere.<\/p>\n

DWI <\/strong>precizeaz\u0103 nucleu infarctului ischemic, \u00een general ireversibil \u0219i anun\u021b\u0103 volumul infarctului final \u2013 cu varia\u021bii medii de 20%. \u00cen caz de tromboliz\u0103, o parte a restric\u021biei de difuzie a zonei anormale DWI poate fi reversibil\u0103, \u00een special la nivelul substan\u021bei albe; Valorile ADC din imaginile de difuzie sunt importante \u00een evaluarea\u00a0 posibilit\u0103\u021bii transform\u0103rilor hemoragice \u0219i \u00een evaluarea viabilit\u0103\u021bii tisulare.<\/p>\n

Perfuzia IRM (PWI)<\/strong> este o tehnic\u0103 care permite observarea fluxului sangvin la nivelul microvasculariza\u021biei cerebrale, cu ajutorul substan\u021bei de contrast Gd, capabil\u0103 s\u0103 determine v\u00e2rsta \u0219i extinderea infarctului \u0219i s\u0103 delimiteze zona infarctat\u0103 (,,core\u201d) de penumbra ischemic\u0103 (\u021besut cu risc).<\/p>\n

Parametrii PWI: CBV ( volum sanguin cerebral), MTT (timp mediu de tranzit), TTP (timp de \u00eenc\u0103rcare maxim\u0103).<\/p>\n

CBV<\/strong> \u2013 zona far\u0103 perfuzie se potrive\u0219te cu aria cu restric\u021bie de DWI \u0219i reprezint\u0103 nucleul infarctului ischemic. Atunci c\u00e2nd aria cu CBV\u2193>DWI\u2193, infarctul tinde s\u0103 creasc\u0103 \u00een zona de anomalie CBV. Valorile CBV<50% anun\u021b\u0103 infarctare tisular\u0103. CBV crescut denot\u0103 situa\u021bie instabil\u0103: \u021besutul poate s\u0103 se infarctizeze sau nu.<\/p>\n

CBF <\/strong>– c\u00e2nd ocluzia e proximal\u0103,\u00a0 aria cu flux redus este de obicei e mai extins\u0103 dec\u00e2t aria cu DWI\u2193. Supraestimeaz\u0103 m\u0103rimea infarctului final. Este cel mai bun parametru care diferen\u021biaz\u0103 penumbra ,,recuperabil\u0103\u201d\u00a0 de cea ,,irecuperabil\u0103\u201d\u00a0 \u00een pofida interven\u021biei terapeutice.<\/p>\n

MTT<\/strong> – este, \u00een caz de obstruc\u021bii proximale, mai mare dec\u00e2t aria DWI \u0219i reprezint\u0103 penumbra opera\u021bional\u0103; supraestimeaz\u0103 m\u0103rimea final\u0103 a infarctului.<\/p>\n

TTP<\/strong> – \u00een ocluziile proximale, TTP> dec\u00e2t DWI; valorile TTP de 6-8 s se coreleaz\u0103 cu m\u0103rimea infarctului final.<\/p>\n

Conceptul de mismatch DWI\/PW<\/strong>I:<\/p>\n

\u00cen timpul primelor ore dup\u0103 debutul AVC, regiunile cu perfuzie anormal\u0103 sunt tipic mai largi dec\u00e2t leziunile decelabile DWI. Se ob\u021bine prin suprapunerea extensiei DWI cu cea a PWI (match vs mismatch). Prin fuziune, \u00een cele mai multe cazuri de mismatch, rezult\u0103 zona\u00a0 de penumbr\u0103 ischemic\u0103<\/strong>, decisiv\u0103 pentru instituirea tratamentului trombolitic de recanalizare.<\/p>\n

Raportul de m\u0103rime \u00eentre PWI si DWI: <\/strong><\/p>\n\n\n\n\n\n\n\n\n
Pattern<\/strong><\/td>\ncauz\u0103 <\/strong><\/td>\nIndica\u021bii<\/strong><\/td>\n<\/tr>\n
PWI f\u0103r\u0103 DWI<\/td>\nocluzie proximal\u0103 sau stenoz\u0103 critic\u0103, cu perfuzarea penumbrei prin circula\u021bie colateral\u0103.<\/td>\ncandidat la reperfuzie<\/td>\n<\/tr>\n
PWI>DWI<\/td>\nocluzie proximal\u0103 sau stenoz\u0103 critic\u0103, cu penumbr\u0103 reperfuzat\u0103 par\u021bial<\/td>\ncandidat bun pt reperfuzie<\/td>\n<\/tr>\n
PWI=DWI<\/td>\nde regul\u0103, \u00een lacune sau ocluzii distale;<\/p>\n

uneori, ocluzii proximale<\/td>\n

\u2022 tot teritoriul e infarctat, f\u0103r\u0103 \u021besut cu risc;<\/p>\n

\u2022 tromboliza exclus\u0103<\/td>\n<\/tr>\n

PWI<DWI<\/td>\ninfarct lacunar sau distal<\/td>\ntromboliza exclus\u0103<\/td>\n<\/tr>\n
DWI f\u0103r\u0103 PWI<\/td>\ninfarct lacunar sau distal<\/td>\ntromboliza exclus\u0103<\/p>\n

 <\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Cercet\u0103rile actuale se axeaz\u0103 pe extinderea ferestrei terapeutice , iar imagistica are rolul de a ajuta la identificarea pacientilor pentru care acest lucru este posibil. Caracterizarea fiziologic\u0103 a zonei de penumbr\u0103 ischemic\u0103 este complementar\u0103 componentei vasculare din imagistica de perfuzie \u0219i poate fi folosit\u0103\u00a0 \u00een selectare pacien\u021bilor care ar putea beneficia de tromboliz\u0103 dincolo de fereastra terapeutic\u0103 de trei ore.<\/p>\n

Spectroscopia IRM<\/strong> are poten\u021bialul de a detecta schimb\u0103rile metabolice \u00een AVC \u00eenainte ca modific\u0103rile structurale s\u0103 fie vizibile, aduc\u00e2nd astfel informa\u021bii suplimentare asupra zonei de penumbr\u0103. Mismatch-ul lactat\/NAA<\/strong> eviden\u021biaz\u0103 penumbra metabolic\u0103, similar\u0103 cu penumbra eviden\u021biat\u0103 de mismatch-ul DWI\/PWI, dar diferit\u0103 ca evolu\u021bie \u00een timp \u0219i ca extindere spa\u021bial\u0103. Nucleul infarctului este caracterizat de absen\u021ba NAA (marker al viabilit\u0103\u021bii neuronale) \u0219i de valori crescute ale lactatului (produs al glicolizei anaerobe, marker specific hipoxiei celulare), iar zona de penumbr\u0103 poten\u021bial salvabil\u0103 e caracterizat\u0103 de valori normale ale NAA \u0219i de valori crescute ale lactatului.<\/p>\n

Dr. Mircea MEDREA<\/p>\n

MEDINST Diagnostic
\nRom\u00e2no-German<\/p>\n

\"MADinst\"<\/p>\n

Medinst Diagnostic Rom\u00e2no-German func\u021bioneaz\u0103 din anul 1997 \u00een cadrul Institutului Na\u021bional de Neurologie \u0219i Boli Neurovasculare Bucure\u0219ti.<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

Rolul neuroimagisticii \u00een evaluarea pacien\u021bilor cu AVC hiperacut a crescut odat\u0103 cu dezvoltarea terapiilor trombolitice. Dac\u0103 pentru o lung\u0103 perioad\u0103, rolul imagisticii a fost doar unul de excludere a leziunilor […]<\/p>\n","protected":false},"author":6,"featured_media":5243,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[33,277,1],"tags":[442],"class_list":["post-5116","post","type-post","status-publish","format-standard","has-post-thumbnail","category-articole","category-neurologie","category-stiri-noutati","tag-medinst"],"yoast_head":"\nPenumbra ischemic\u0103 \u00een AVC - Jurmed - Medici<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/jurmed.ro\/medici\/penumbra-ischemica-in-avc\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Penumbra ischemic\u0103 \u00een AVC - Jurmed - Medici\" \/>\n<meta property=\"og:description\" content=\"Rolul neuroimagisticii \u00een evaluarea pacien\u021bilor cu AVC hiperacut a crescut odat\u0103 cu dezvoltarea terapiilor trombolitice. 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