{"id":5128,"date":"2015-12-18T11:48:25","date_gmt":"2015-12-18T11:48:25","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=5128"},"modified":"2016-01-20T11:57:43","modified_gmt":"2016-01-20T11:57:43","slug":"irm-structural-si-irm-functional-in-diagnosticarea-si-monitorizarea-bolii-alzheimer","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/irm-structural-si-irm-functional-in-diagnosticarea-si-monitorizarea-bolii-alzheimer\/","title":{"rendered":"IRM structural \u0219i IRM func\u021bional \u00een diagnosticarea \u0219i monitorizarea bolii Alzheimer"},"content":{"rendered":"<p style=\"text-align: justify;\">Boala Alzheimer este forma cea mai \u00eent\u00e2lnit\u0103 de demen\u0163\u0103 care afecteaz\u0103 persoanele v\u00e2rstnice, iar\u00a0inciden\u0163a ei cre\u015fte odat\u0103 cu procesul de \u00eemb\u0103tr\u00e2nire.<\/p>\n<p style=\"text-align: justify;\">Examenul IRM contribuie la excluderea cauzelor chirurgicale ale demen\u021belor, la diagnosticarea timpurie a bolilor neurodegenerative \u015fi la decelarea unor aspecte orientative pentru diagnosticul etiologic sau diferen\u021bial. Markerii imagistici pot sus\u0163ine diagnosticul unor boli neurodegenerative specifice, pot diferen\u021bia \u00eentre diferite patologii neurodegenerative \u015fi sunt necesari \u00een confirmarea diagnosticului \u0219i \u00een monitorizarea progresiei.<\/p>\n<p style=\"text-align: justify;\">Schimb\u0103rile neurobiologice \u00een boala Alzheimer apar \u00eenainte de apari\u021bia simptomelor \u0219i implic\u0103 atrofia de lob temporal medial (cortexul entorhinal \u0219i hipocampusul) urmat\u0103 de o deteriorare progresiv\u0103 neocortical\u0103. Boala Alzheimer este asociat\u0103 cu acumul\u0103ri anormale de proteine <em>tau<\/em> \u0219i de \u03b2-amiloid care duc la deterior\u0103ri progresive sinaptice, neuronale \u0219i axonale. IRM structural estimeaz\u0103 deterior\u0103rile sau pierderile de \u021besut \u00een regiunile cerebrale vulnerabile caracteristice. Atrofia cerebral\u0103 detectat\u0103 imagistic prin rezonan\u021b\u0103 magnetic\u0103 este corelat\u0103 cu degenerescen\u021ba neurofibrilar\u0103 \u0219i cu deficite neurofiziologice \u0219i este un marker valid pentru BA \u0219i pentru progresia bolii. Deficitul de memorie timpuriu corespunde atrofiilor de cortex entorhinal, de hipocampus \u0219i de cortex cingulat posterior. Deficitele verbale, vizuo-spa\u021biale \u0219i comportamentale sunt asociate cu pierderea neuronal\u0103 \u0219i cu atrofii ale cortexului temporal, parietal \u0219i frontal.<\/p>\n<p style=\"text-align: justify;\">Gradul de atrofie a structurilor mediale temporale precum hipocampusul este un marker diagnostic pentru AD \u00een stadiul MCI. Atrofia de lob temporal medial, de\u0219i este pozitiv\u0103 \u0219i \u00een alte forme de demen\u021b\u0103, este senzitiv\u0103 pentru diagnosticul bolii Alzheimer, un grad mare de atrofie fiind prezent \u00een 100% din cazuri. Pe de alt\u0103 parte, la un pacient cu deficit cognitiv minor, ce poate fi un stadiu pre-Alzheimer, un scor negativ va exclude dezvoltarea ulterioar\u0103 a bolii Alzheimer. Pentru progresia de la MCI la stadiul de demen\u021b\u0103 moderat\u0103 Alzheimer, markerii structurali sunt mult mai senzitivi la modific\u0103ri dec\u00e2t markerii pentru depozitele de \u03b2-amiloid.<\/p>\n<p style=\"text-align: justify;\">Metodele de determinare a atrofiei de lob temporal sunt: scalele vizuale de rating, m\u0103suratori liniare ale structurilor LT, volumetria hipocampic\u0103. Cea mai cunoscut\u0103 <strong><em>scal\u0103 de rating vizual<\/em><\/strong> se bazeaz\u0103 pe evaluarea grosimii fisurii coroidale, a grosimii cornului temporal \u0219i a \u00een\u0103l\u021bimii hipocampului (tehnica: imagini T1 ponderate cu rezolu\u021bie \u00eenalt\u0103 \u00een plan coronal, perpedincular pe axul lung al LT).<\/p>\n<p style=\"text-align: justify;\">\u00cen evaluarea BA, al\u0103turi de atrofia de lob temporal medial se urm\u0103re\u0219te \u0219i atrofia parietal\u0103, care are o valoare predictiv\u0103 pozitiv\u0103 \u00een diagnosticul bolii \u0219i o diferen\u021biaz\u0103 de demen\u021ba fronto-temporal\u0103. \u00cen particular, atrofia de gir precuneus este caracteristic\u0103 BA. Scorul Koedam evalueaz\u0103 atrofia parietal\u0103 prin gradul de l\u0103rgire a \u0219anturilor cingulat posterior \u0219i parieto-occipital \u00een cele 3 planuri (sagital, coronal and axial). L\u0103rgirea spa\u021biilor ventriculare este cea mai reproductibil\u0103 m\u0103sur\u0103toare a progresiei BA: 5-16%\/an \u00een BA, fa\u021b\u0103 de 1,5-3%\/an la v\u00e2rstnicii s\u0103n\u0103to\u0219i.<\/p>\n<p style=\"text-align: justify;\">Rata de atrofie cerebral\u0103 global\u0103 apare cu aproximativ 4 ani \u00eenainte de trecerea pragului de demen\u021b\u0103 \u0219i are o rat\u0103 de progresie de 1,4-2,2% \/an. \u00cen \u00eemb\u0103tr\u00e2nirea normal\u0103 este de aprox. 0,7%\/an.<\/p>\n<p style=\"text-align: justify;\">Protocolul IRM structural:<\/p>\n<ul style=\"text-align: justify;\">\n<li>T1 \u2013 pentru evaluarea atrofiei hipocampice \u015fi de lob temporal medial; Scanarea se face \u00een sec\u0163iuni coronale sub\u0163iri, perpendiculare pe axul lung al hipocampului;<\/li>\n<li>FLAIR \u2013 pentru evaluarea atrofiei corticale globale. Posibilele leziuni vasculare apar \u00een hipersemnal, iar lacunele \u00een hiposemnal. Achizi\u021bia se face \u00een plan transversal;<\/li>\n<li>T2 \u2013 pentru evaluarea lacunelor, \u00een particular a celor din ganglionii bazali, ce pot fi confundate pe FLAIR cu spa\u0163ii perivasculare Virchow- Robin;<\/li>\n<li>SWI \u2013 pentru detectarea microhemoragiilor (angiopatia hipertensiva, angiopatia amiloida), depozitelor de Fe \u0219i microcalcific\u0103rilor.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Un alt semn imagistic al bolilor neurodegenerative este prezen\u021ba \u00een exces a depozitelor de hemosiderin\u0103 \u0219i a leziunilor microhemoragice, detectabile prin secven\u021ba de rutin\u0103 T2* sau SWI (Susceptibility Weighted Imaging). <strong>SWI <\/strong>este cea mai eficient\u0103 metod\u0103 imagistic\u0103 de eviden\u0163iere a leziunilor microhemoragice \u015fi a depozitelor de hemosiderin\u0103. Unul din cinci pacien\u0163i cu AD au cel pu\u0163in o leziune microhemoragic\u0103 (dou\u0103 cauze posibile: patologia vascular\u0103 sau angiopatia cerebral\u0103 amiloid\u0103). Prezen\u0163a crescut\u0103 a microhemoragiilor \u00een AD arat\u0103 cursul agresiv al bolii, indic\u00e2nd declin cognitiv sever \u015fi cre\u015fterea riscului de deces.<\/p>\n<p style=\"text-align: justify;\">Markerii IRM structural\/morfologic sunt inclu\u0219i \u00een criteriile de diagnostic pentru non-AD precum demen\u021ba vascular\u0103, demen\u021ba frontotemporal\u0103, demen\u021ba cu corpi Lewy, Creutzfeldt-Jacob \u0219i sunt folosi\u021bi pentru diagnosticul diferen\u021bial.<\/p>\n<p style=\"text-align: justify;\"><strong>IRM func\u021bional<\/strong><\/p>\n<p style=\"text-align: justify;\">Atrofia este acompaniat\u0103 de pierderi microstructurale dendritice, mielinice \u0219i axonale \u0219i de modific\u0103ri ale metaboli\u021bilor. Tehnicile IRM avansate precum spectroscopia, DWI \u0219i DTI sunt mai sensibile la modific\u0103rile metabolice \u0219i microstructurale, sunt sensitive la schimb\u0103rile timpurii \u0219i aduc informa\u021bii suplimentare privind evolu\u021bia bolii. fMRI si tehnicile de perfuzie (PWI sau ASL) sunt sensibile la consecin\u021bele func\u021bionale ale acestor modific\u0103ri \u0219i sunt utile pentru detec\u021bia BA \u00een stadiul preclinic \u0219i pentru stabilirea conduitei terapeutice.<\/p>\n<p style=\"text-align: justify;\"><strong>Spectroscopia RM <\/strong>este o tehnic\u0103 care poate monitoriza in vivo modific\u0103rile metabolice care \u00eenso\u0163esc schimb\u0103rile structurale cerebrale \u015fi poate fi aplicat\u0103 \u00een evaluarea imagistic\u0103 a bolii Alzheimer. Prin cuantificarea unor metaboli\u0163i precum N-Acetilaspartat (NAA) \u015fi mioinositol, spectroscopia RM este un instrument de monitorizare a evolu\u0163iei bolii.<\/p>\n<p style=\"text-align: justify;\"><strong>NAA (N-acetilaspartat)<\/strong> &#8211; este un marker al viabilit\u0103\u021bii neuronale. Are valori sc\u0103zute \u00een procesele de distruc\u021bie neuronal\u0103. Nivelul sc\u0103zut de N-AA este marker al declinului cognitiv.<\/p>\n<p style=\"text-align: justify;\"><strong>Cho (colina)<\/strong> &#8211; precursor al membranei celulare neuronale \u0219i gliale; este un al densit\u0103\u021bii celulare \u0219i al permeabilit\u0103\u021bii membranare. Este un metabolit care prezint\u0103 niveluri crescute \u00een tumori maligne \u0219i boli demielinizante. Distrugerea membranelor, dar \u0219i proliferarea celular\u0103 induce cre\u0219terea cholinei =&gt; marker membranar (cre\u0219te at\u00e2t \u00een leziuni, dar \u0219i \u00een procesele de refacere),<\/p>\n<p style=\"text-align: justify;\"><strong>Cr (creatina)<\/strong> \u2013 reflect\u0103 poten\u021bialul energetic disponibl \u00een \u021besutul cerebral. Concentra\u021bia sa \u00een \u021besutul cerebral s\u0103n\u0103tos r\u0103m\u00e2ne foarte \u00eenalt\u0103 \u0219i stabil\u0103. Cr\/PCr (creatin\u0103\/phosfocreatin\u0103) &#8211; index al densit\u0103\u021bii celulare, marker al statusului energetic neuronal\/glial. Are o concentra\u021bie mai mare \u00een celulele gliale dec\u00e2t \u00een neuroni.<\/p>\n<p style=\"text-align: justify;\"><strong>Lactate (Lac)<\/strong>\u00a0\u2013 marker al proceselor oxidative; este absent \u00een \u021besutul cerebral normal, iar prezen\u021ba sa este un indicator al glicolizei anaerobe la nivel celular. Nivelurile ridicate de lactat sunt asociate cu procesele ischemice sau cu tulbur\u0103rile metabolice, dar este prezent \u0219i la periferia tumorilor cerebrale.<\/p>\n<p style=\"text-align: justify;\"><strong>MI<\/strong> <strong>(mioinositol)<\/strong> &#8211; marker glial \u0219i astrocitar. Fluctua\u021bia concentra\u021biei este mai mare dec\u00e2t la orice alt metabolit. Cre\u0219te \u00een afec\u021biuni sistemice \u0219i scade \u00een stroke, tumori, limfom \u0219i p\u00e2n\u0103 aproape de zero \u00een encefalopatia hepatic\u0103.<\/p>\n<p style=\"text-align: justify;\">Sc\u0103derile de N-acetilaspartat \u015fi cre\u015fterile nivelului de mioinositol se coreleaz\u0103 cu o sc\u0103dere a func\u0163iei cognitive. Prezen\u0163a pl\u0103cilor senile (acumul\u0103ri de \u03b2-amiloid \u00een termina\u021biile presinaptice ale neuronilor care \u00eempiedic\u0103 tranmsiterea inflluxului nervos), caracteristic\u0103 \u00een boala Alzheimer, este asociat\u0103 cu pierderea neuronal\u0103 care se reflect\u0103 \u00eentr-o sc\u0103dere a markerului neuronal N-acetilaspartat (NAA), iar cre\u0219terea mio-inositolului reflect\u0103 glioza. Un rezultat suplimentar decelat la pacien\u0163ii cu boala Alzheimer este cre\u015fterea metabolitului mioinositol, care este un metabolit produs de astrocitele care \u00eenconjoar\u0103 pl\u0103cile senile. Utilizarea raportului NAA\/mioinositol este cea mai bun\u0103 metod\u0103 de diferen\u0163iere a pacien\u0163ilor cu boala Alzheimer de subiec\u0163ii s\u0103n\u0103to\u015fi. Fa\u021b\u0103 de subiec\u021bii normali, pacien\u021bii cu BA prezint\u0103 valori mai sc\u0103zute ale raportului NAA\/Cr \u0219i ale NAA\/MI \u0219i valori mai crescute ale raportului Cho\/Cr \u0219i MI\/Cr. Utilizarea raportului NAA\/mio-inositol este cea mai bun\u0103 metod\u0103 de diferen\u0163iere a pacien\u0163ilor cu boala Alzheimer de subiec\u0163ii s\u0103n\u0103to\u015fi.<\/p>\n<p style=\"text-align: justify;\"><strong>DWI<\/strong> <strong>(Diffusion Weighted Imaging)<\/strong><\/p>\n<p style=\"text-align: justify;\">\u00cen timpul procesului de mielinizare (p\u00e2n\u0103 \u00een decada a treia) exist\u0103 o cre\u0219tere a anizotropiei frac\u021bionale (FA) \u0219i o sc\u0103dere a coeficientului aparent de difuzie (ADC) la nivelul SA. Difuzia se modific\u0103 la v\u00e2rste \u00eenaintate, suger\u00e2nd demielinizare \u0219i pierdere axonal\u0103, lucru confirmat de studiile anatomo-patologice. La v\u00e2rste \u00eenaintate, se constat\u0103 un declin al FA at\u00e2t la nivel cerebral global, c\u00e2t \u0219i \u00een substan\u021ba alb\u0103. Anomaliile microstructurale sugerate de difuzia RM par s\u0103 se coreleze cu m\u0103sur\u0103torile func\u021biilor cognitive \u0219i motorii \u0219i sunt utile \u00een identificarea pacien\u021bilor cu demen\u021b\u0103.<\/p>\n<p style=\"text-align: justify;\">Rezonan\u0163a magnetic\u0103 func\u0163ional\u0103 de repaus <strong>(rsFMRI)<\/strong> este o alt\u0103 metod\u0103 imagistic\u0103 folosit\u0103 \u00een caracterizarea bolii Alzheimer. \u00cen repaus, creierul uman prezint\u0103 oscila\u0163ii ale semnalului BOLD (Blood Oxygenation Level Dependent), iar unele regiuni cerebrale arat\u0103 c\u0103 au acelea\u015fi frecven\u0163e de oscila\u0163ie ale semnalului BOLD (sunt conectate). Cea mai u\u015for reproductibil\u0103 re\u0163ea de zone interconectate \u00een repaus este re\u0163eaua de baz\u0103, a\u015fa numita \u201cdefault mode network\u201d, care se suspend\u0103 (dezactiveaz\u0103) \u00een timpul comportamentelor de \u00eendeplinire a unor sarcini. Studii recente arat\u0103 c\u0103 exist\u0103 diferen\u0163e \u00eentre adul\u0163ii v\u00e2rstnici s\u0103n\u0103to\u015fi \u015fi cei cu boala Alzheimer la nivelul default mode network: dezactivarea ineficient\u0103 poate fi un indicator pentru BA precoce. Activarea redus\u0103 \u00een stare de repaus \u00een ariile \u201cdefault mode network\u201d este obi\u0219nuit\u0103 \u00een \u00eemb\u0103tr\u00e2nire \u0219i e legat\u0103 de disfunc\u021bii \u00een execu\u021bie \u0219i de \u00eencetinirea vitezei de procesare.<\/p>\n<p style=\"text-align: justify;\">Metoda tractografiei de difuzie <strong>(DTI)<\/strong> este o alt\u0103 metod\u0103 relativ recent\u0103 care pune \u00een eviden\u0163\u0103 modific\u0103ri morfologice \u015fi func\u0163ionale ale substan\u0163ei albe. Imagistica tensorului de difuzie (DTI), furnizeaz\u0103 o sensibilitate crescut\u0103 la modific\u0103rile din microstructura substan\u021bei albe <em>in vivo<\/em> \u0219i este deosebit de eficient\u0103 \u00een depistarea bolilor care provoac\u0103 deteriorare axonal\u0103 \u0219i demielinizare. Pacien\u021bii cu Alzheimer prezint\u0103 o cre\u0219tere semnificativ\u0103 a difuzibilit\u0103\u021bii axiale (paralel\u0103 cu fibrele axonale) \u0219i a celei radiale (perpendicular\u0103 pe fibrele axonale). Se \u015ftie c\u0103 \u00een boala Alzheimer cele mai afectate tracturi cerebrale sunt fasciculul uncinat, fasciculul cingular, corpul calos \u015fi fasciculul longitudinal superior, num\u0103rul fibrelor e mai sc\u0103zut, iar difuzivitatea medie e m\u0103rit\u0103 la pacien\u0163i fa\u0163\u0103 de normali. La pacien\u0163ii cu Alzheimer, cre\u015fterea difuzivit\u0103\u0163ii medii \u015fi reducerea anizotropiei frac\u0163ionale a fost raportat\u0103 \u00een mai multe regiuni, incluz\u00e2nd lobii temporali \u015fi parietali \u015fi \u00eentr-o m\u0103sur\u0103 mai mic\u0103, lobul frontal. Exist\u0103 corel\u0103ri semnificative \u0219i echivalente din punct de vedere anatomic \u00eentre modific\u0103rile de substan\u021b\u0103 alb\u0103 \u0219i atrofia regional\u0103 de substan\u021b\u0103 cenu\u0219ie.<\/p>\n<p style=\"text-align: justify;\">Diagnosticul precoce al bolii Alzheimer e important, \u00een special pentru a identifica pacien\u0163ii ce ar putea beneficia de terapii recente, precum anti- amiloidaza. Eforturile care se fac \u00een imagistic\u0103 pentru diagnosticarea \u015fi stadializarea bolii Alzheimer, fac parte dintr-un efort general de lupt\u0103 \u00eempotriva acestei patologii, \u00een condi\u0163iile unei \u00eemb\u0103tr\u0103niri a popula\u0163iei lumii.<\/p>\n<p style=\"text-align: justify;\">Echipa medicala\u00a0MEDINST Diagnostic<br \/>\nRom\u00e2no-German<\/p>\n<p style=\"text-align: justify;\"><a href=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945.jpg\" rel=\"attachment wp-att-4113\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-4113\" src=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945-300x90.jpg\" alt=\"MADinst\" width=\"300\" height=\"90\" srcset=\"https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945-300x90.jpg 300w, https:\/\/jurmed.ro\/medici\/wp-content\/uploads\/sites\/2\/2015\/02\/MEDinst-logograma-claim_4c_P2945.jpg 800w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p style=\"text-align: justify;\"><strong>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":"<p>Boala Alzheimer este forma cea mai \u00eent\u00e2lnit\u0103 de demen\u0163\u0103 care afecteaz\u0103 persoanele v\u00e2rstnice, iar\u00a0inciden\u0163a ei cre\u015fte odat\u0103 cu procesul de \u00eemb\u0103tr\u00e2nire. Examenul IRM contribuie la excluderea cauzelor chirurgicale ale demen\u021belor, [&hellip;]<\/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":[33,77],"tags":[442],"class_list":["post-5128","post","type-post","status-publish","format-standard","has-post-thumbnail","category-articole","category-psihiatrie","tag-medinst"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>IRM structural \u0219i IRM func\u021bional \u00een diagnosticarea \u0219i monitorizarea bolii Alzheimer - 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\/irm-structural-si-irm-functional-in-diagnosticarea-si-monitorizarea-bolii-alzheimer\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"IRM structural \u0219i IRM func\u021bional \u00een diagnosticarea \u0219i monitorizarea bolii Alzheimer - Jurmed - Medici\" \/>\n<meta property=\"og:description\" content=\"Boala Alzheimer este forma cea mai \u00eent\u00e2lnit\u0103 de demen\u0163\u0103 care afecteaz\u0103 persoanele v\u00e2rstnice, iar\u00a0inciden\u0163a ei cre\u015fte odat\u0103 cu procesul de \u00eemb\u0103tr\u00e2nire. 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