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Тромболизис при инсульте показания и противопоказания

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17 августа 2019

Инсульт оказывает значительное влияние на здоровье населения и является третьей по величине причиной смертности в мире.

Ишемический инсульт является одной из основных причин тяжелой постинсультной инвалидизации взрослого населения.

Тромболизис при ишемическом инсульте призван снизить негативные симптомы инсульта и уменьшить вероятность инвалидности больного.

Что представляет собой тромболитическая терапия?

Ишемический инсульт обычно возникает из-за внутрисосудистого тромба, перекрывающего мозговой кровоток.

После начала развития инсульта, нейроны, окружающие ишемическое ядро, могут оставаться жизнеспособными в течение определенного периода времени.

Разрушение клеток головного мозга после ишемии происходит постепенно, и восстановление кровяного потока с помощью ранней его коррекции может спасти поврежденные нейроны.

Сгустки крови, перекрывающие мозговой кровоток, могут быть лизированы (растворены). Тромболизис (тромболитическая терапия) проводится методом растворения кровяных сгустков (тромбов), перекрывающих кровеносный сосуд с помощью тромболитических препаратов.

Тромболизис – вид фармакологической терапии, направленный на восстановление кровотока в сосуде за счет растворения тромба под действием различных агентов внутри сосудистого русла.

Тромболизис при остром ишемическом инсульте является ключевым вмешательством, которое может уменьшить инвалидность.

Тромболитическая терапия проводится методом ввода в вены больного алтеплазы (г-ТАП) – вещества, относящегося к группе тромболитических средств.

Алтеплаза действует путем преобразования неактивного плазминогена в активную форму плазмин, который способствует тромболизису фибрина путем его расщепления.

Процедура лизирования выполняется введением в кровоток пациента 0,9 мг алтеплазы (г-ТР) на 1 килограмм веса пациента в течение 60 минут (но не более 90 мг), при этом 10% даются в виде болюса.

Имеются два вида тромболизиса, направленные на освобождение блокированного сосуда от тромба.

Тромболизис с применением тромболитических агентов

  • Эминазу (Анистреплазу);
  • Ретавазу (Ретеплазу);
  • Стрептазу (Стрептокиназу, Кабикиназу);
  • ТАП (класс препаратов, который включает в себя Активазу);
  • Тенектеплазу;
  • Аббокиназу, Кинлитик (Урокиназу).

В зависимости от картины развития инсульта, врач может выбрать один из перечисленных вариантов медикаментозного лечения.

Препарат обычно вводится через длинный катетер, направляемый в кровеносный сосуд непосредственно к месту образования тромба, чтобы доставить лекарства непосредственно к месту закупорки сосуда.

Во время тромболизиса врач использует рентгенологического томографию, чтобы видеть результат растворения тромба. Если тромб является относительно небольшим, процесс лизирования может занять несколько часов. Для лечения тяжелой закупорки сосуда может потребоваться несколько дней.

ВОЗ объявила об увеличении количества людей, страдающих эпилепсией после инсульта. Почему развиваются припадки после приступа? Попробуем разобраться.

О том, как предупредить инсульт, должен знать каждый. Эта информация важна для всех.

Что такое мигренозный инсульт и насколько он опасен? Если вы часто страдаете мигренями, то эта статья для вас.

Механическая тромбоэмболия

Врачи также могут выбрать другой тип тромболизиса, называемый механической тромбоэмболией.

Во время этой процедуры, длинный катетер, имеющий наконечник с маленькой манжетой и поворотным устройством, вводится в кровеносный сосуд.

Для физического разрушения тромба используется высокоскоростная струя жидкости или ультразвуковое излучение.

Показания и противопоказания

Тромболитическая терапия, направленная на восстановление мозгового кровотока, имеет доказанную пользу для некоторых пациентов с острой церебральной ишемией и может привести к разрешению или улучшению острого неврологического дефицита.

Острый неврологический дефицит при инсульте включает недостаточную подвижность конечностей и тела больного и изменения в его интеллектуальной, чувствительной и эмоциональной сферах.

Существует две точки зрения на проведение тромболитической терапии, основанные на статистических данных:

  1. Тромболизис благоприятно влияет на мозговую симптоматику.
  2. Повышение риска внутричерепного кровоизлияния при тромболитической терапии оставляет летальность на прежнем уровне.

Исследования пациентов, перенесших инсульт и прошедших тромболитическую терапию, указывают на то, что:

  1. Внутривенная фибринолитическая терапия в течение первых 3 часов после начала ишемического инсульта предлагает значительные выгоды практически у всех больных с потенциально инвалидизирующим дефицитом.
  2. Внутривенная фибринолитическая терапия в течение 3-4,5 часов после начала инсульта предлагает умеренные преимущества, когда применяется ко всем больным с потенциально инвалидизирующим дефицитом.
  3. Внутриартериальная фибринолитическая терапия в период от 3 до 6 часов предлагает умеренные преимущества, при применении для всех пациентов с потенциально инвалидизирующим дефицитом и тромботический окклюзией большой артерии головного мозга.
  4. Своевременное МРТ степени ядра инфаркта головного мозга больного (необратимо поврежденной ткани) и полутени (ткани риска, которую еще можно спасти), может повысить терапевтический выход литической терапии, особенно в период от 3- до 9- часового окна.

Основные барьеры для проведения тромболизиса включают в себя:

  1. Недостаточную информированность общественности и недоступность неотложных медицинских услуг.
  2. Около 80% пациентов неотложной помощи попадают в выход из «оконного периода» эффективности указанной терапии, то есть они прибывают в отделение через 4,5 часа после появления первых признаков инсульта.
  3. После процедуры визуализации с помощью МРТ около 70% пациентов исключаются из кандидатов на проведение терапии. Из них около 60% имеют внутричерепное кровоизлияние, у 14% отмечена транзиторная ишемическая атака и произошло улучшение неврологических симптомов, родственники примерно 6% больных отказываются дать согласие на тромболизис, у 5,7% больных был зафиксирован диагноз метаболического расстройства (гипогликемия, гипергликемия, гипонатриемия).
  4. Другими причинами исключения из терапии является пост-иктальный статус больного, недавний тромболизис, недавняя хирургическая операция, задержка в контакте с рентгенологом и часто отсутствующее время для принятия согласованного с родственниками больного необходимого решения. Еще один сложный вопрос тромболитической терапии – экономический. Стоимость препаратов и принимаемых мер довольно высока.
  1. Прошло не более 3 – 4,5 часов после начала симптомов инсульта.
  2. Исключен геморрагический характер инсульта и гарантированно исключено сосудистое кровоизлияние.
  3. У больного имеется значительный неврологический дефицит, связанный с инсультом головного мозга.
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Заключение

Тромболизис при остром ишемическом инсульте, хоть и рассматривается в целом благоприятно при высоком неврологическом дефиците, по мнению многих врачей является спорным вмешательством, показывающим риски, сопоставимые с пользой тромболитической терапии.

Внедрение нормальных реабилитационных программ, связанных с инсультом, призвано снять ряд возникающих неврологических проблем на начальных этапах развития заболевания.

У многих заболеваний имеются психосоматические причины. Психосоматика инсульта — как ревность, ненависть и стремление к достижениям может привести к опасной болезни.

Какое давление у человека бывает при инсульте, читайте в этом материале.

Видео на тему

Самой распространенной болезнью, связанной с сосудами головного мозга, является ишемический инсульт. Этот инфаркт головного мозга поражает до необратимости только часть клеток и только в первые минуты.

Остальные же клетки могут минимально функционировать и быть активными еще определенное время, незначительное, но иногда достаточное, чтобы спасти человека без потери его работоспособности.

Тромболитическая терапия при ишемическом инсульте, по мнению медиков,это единственная возможность таким пациентам свести до минимума последствия инсульта и не дать ему развиться дальше. Так ли это?

Тромболитическая терапия — это…

Тромболизис при инсульте — это фармакологическая терапия, которая призвана наладить кровоток в поврежденном сосуде с помощью лизиса или растворения тромбов внутри этого кровяного русла. Действие процедуры базируется на том, что плазиноген переводят в активное состояние, и он становится плизмином. Вещество активирует фибринолитические способности крови, и тромб растворяется.

Наивысшая эффективность процедуры достигается, если с момента образования тромба прошло не более 12 часов.

Важно! Эта терапия может применяться только при ишемической форме болезни, а при кровоизлиянии она категорически запрещена.

Этой терапии предшествовала единственная на тот момент процедура стандартного тромболизиса, при которой растворение тромба происходило за счет капельницы со специальным препаратом длительностью 1 час. Такой тромболизис при ишемическом инсульте, несмотря на свою простоту и удобство, имел 2 существенных недостатка, которые снижали его эффективность:

  1. Для процедуры нужен был тщательный осмотр и анализы, на которые могли уйти часы, сокращающие шансы больного на выживание.
  2. Большой список ограничений и осложнений. Например, любая операция, проведенная незадолго до инсульта, относилась к противопоказаниям. А самым частым осложнением являлся переход ишемии в болезнь геморрагического типа.

Противопоказания и осложнения не позволяли спасти тысячи жизней, поэтому медики и ученные разработали тромболизис селективного типа. Благодаря ему можно оказать помощь больному с первой секунды появления проблемы, а значит, свести на нет ее серьезные последствия. На практике используются обе методики, и какую выбрать решает врач, ориентируясь на каждую конкретную ситуацию.

Более современная процедура подразумевает введение медицинского препарата непосредственно в артерию. Чаще всего пункцию проводят на бедренной артерии. С помощью микрокатетера, вставленного в кровяное русло, лекарство доставляется непосредственно в поврежденный мозговой сосуд. А традиционная методика подразумевает введение активного вещества через капельницу внутривенно.

Анамнез и не только

Проведение процедуры и подбор необходимых тромболитиков начинаются с диагностики, которую назначают после изучения жалоб пациента и его анамнеза. К ним относятся:

  1. Слепота транзиторного и монокулярного типа.
  2. Любые патологии сердца.
  3. Диагнозы «стенокардия» или «ишемия нижних конечностей».
  4. Сильная утомляемость после пробуждения, приема ванны с горячей водой, незначительной физической нагрузки.
  5. Признаки развития неврологических симптомов.
  6. Возраст от 50 лет.

В случаях, когда невралгическая симптоматика становится очаговой и начинает преобладать над мозговой, тромболизис будет назначен. Чаще всего это:

  • головные боли, сопровождающиеся головокружениями;
  • неустойчивая походка и шатание;
  • критическое нарушение симметрии лица;
  • сбивчивость речи;
  • помутнение сознания;
  • тремор, слабость и онемение рук и ног;
  • припадок судорожного типа;
  • нарушение зрительной, слуховой, дыхательной функции;
  • рвота и тошнота;
  • учащенное сердцебиение и боль в сердце;
  • температура.

Диагностика

Благодаря тому, что медицина не стоит на месте, все диагностические мероприятия не занимают много времени. Это позволяет начать тромболизис в первые часы после ишемического инсульта. Диагностические мероприятия принято разделять на основные и дополнительные. Обычно хватает результатов первых, но не нужно исключать случаев, когда без дополнительных процедур не обойтись.

К стандартным, или основным диагностическим мероприятиям относят:

  • общий анализ крови;
  • проверку уровня глюкозы в крови;
  • проверку холестерина как по общему анализу, так и по структурированному;
  • анализ крови на уровень электролитов;
  • проверку печеночных трансаминаз и билирубина общего и прямого;
  • анализ мочевины, креатинина, общего белка;
  • коагулограмму;
  • ОАМ, ЭКГ;
  • круглосуточный КТ, МРТ, УЗИ.

Дополнительно могут назначить:

  • проверку антинуклеарных факторов антител к волчаночному антикоагулянту, кардиолипинам и т. п.;
  • анализ протеинов и белковых фракций;
  • КФТ и тропониновый тест;
  • проверку крови на венерические заболевания и ВИЧ;
  • артериальное МСКТА или МРА;
  • ЭЭГ;
  • рентген;
  • УЗИ или УЗДГ брюшины, почек;
  • пункцию люмбального типа.
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Медикаментозные препараты

Лекарства для проведения тромболиза называют тромболитиками или активаторами плазминогена. Используемые ранее препараты, относящиеся к группе гепаринов, только замедляли формирование тромбов. А современные тромболитики их еще и разрушают, что приводит не только к восстановлению кровотока поврежденного сосуда, но и препятствует в дальнейшем образованию новых тромбов.

Для тромболитической терапии используют следующие препараты:

  • первое поколение — Стрептокиназа и Урокиназа;
  • второе поколение — Альтеплаза, Актилизе, Проурокиназа;
  • третье поколение — это тандем Тенектеплазы, Метализы, Ретаплазы.

Помимо этого, проводят антигипертензивную терапию. Обычно при ишемическом инсульте, находящемся в острой стадии, давление не понижают, даже если речь идет о показателе 220/110 мм рт. ст. Однако в редких случаях его снижают на 10-20% за первые два часа, затем на 5% каждый последующий час.

Важно! Артериальное давление приводят к нормативным значениям в более интенсивном темпе для пациентов с инфарктом миокарда, острой сердечной и почечной недостаточностью, диссекцией аорты и гипертонической энцефалопатией. Важно не допустить стремительных скачков давления.

Для этих целей используют следующие лекарства с антигипертензивными свойствами:

  • Каптоприл, Эналаприл, Периндоприл, относящиеся к ингибиторам АПФ;
  • Эпросартан или Кандесартан — антагонисты рецепторов;
  • Пропранолол и Проксодолол, относящиеся к бета и альфа-блокаторам соответственно;
  • Клонидин — агонист центральных альфа-адренорецепторов;
  • Нитропруссид — вазодилататор.

Важно проводить полноценную коррекцию гиповолемии. При этом используют раствор хлорида натрия, его объем корректируется в зависимости от необходимого уровня гематокрита. В среднем принято ориентироваться на 1,5-2,8 литра жидкости с положительным коэффициентом.

Если речь идет об отеке мозга, легких, сердечной недостаточности, то водный баланс делают с отрицательным коэффициентом. При риске повышения внутричерепного давления гипоосмолярные растворы не применяют.

Обязательно следят за уровнем глюкозы. Когда ее уровень в крови снижается до уровня 10 ммоль/л, необходимы подкожные инъекции инсулина. Если пациент страдает сахарным диабетом, то его также переводят на подкожные инъекции короткого действия. Контроль уровня глюкозы проводят через час после каждой инъекции.

Судорожный синдром купируют Диазепамом, вальпроевой кислотой, Карбамазепином. Если регистрируют рефрактерный эпилептический статус, то вводят Тиопентал натрия, Профол.

Тромболитическая терапия: противопоказания

Результативность и эффективность процедуры хоть и большая, но и она имеет серьезные противопоказания, которые делают ее проведение невозможной некоторым пациентам. К ним относят:

  1. Кровотечения любого типа и с любой локализацией, и связано это с тем, что тромболизис растворит даже те тромбы, которые должны остановить кровь в том месте, где необходимо.
  2. Расслоение аорты.
  3. Гипертензия артериального типа.
  4. Внутричерепная опухоль любой этиологии.
  5. Геморрагический инсульт.
  6. Болезни печени в острой форме.
  7. Операционное вмешательство, недавно проведенное.
  8. Беременность.

Важно! Возраст больного не является препятствием для проведения тромболитической терапии, более того, чем моложе пациент, тем лучше и быстрее достигается нужный эффект.

Лечение немедикаментозного типа

При ишемическом инсульте проводят также немедикаментозное лечение, заключающее в следующем:

  1. Больного нужно доставить в больницу в кратчайшие сроки, желательно в течение первых трех часов с момента приступа. Это должен быть инсультный центр или невралгическое отделение.
  2. Пациента помещают в блок интенсивной терапии или проводят ОАРИТ, соответствующий показаниям.
  3. Мониторинг всех жизненно важных функций.
  4. Пару дней больному обеспечивается постельный режим с постепенной вертикализацией.
  5. При необходимости восстанавливают проходимость дыхательных путей.
  6. ИВЛ по необходимости и показаниям.
  7. Диетический режим:
  • первые пару дней вся еда должна быть отварной и перетертой, чтобы организму ее было легче переваривать и усваивать;
  • количество потребляемых жиров уменьшают до минимума, это касается не только животных жиров, но и растительных;
  • минимизировать количество соли до 3 грамм в сутки;
  • количество сложных углеводов и клетчатки должно превалировать в рационе;
  • овощи и фрукты — это 1/3 рациона;
  • жаренная, копченая, соленая пища под запретом;
  • хлеб только из муки грубого помола и с отрубями.

Медики настоятельно рекомендуют всем пациентам, которые склонны к возникновению инсульта любого типа, вести здоровый образ жизни. А это и правильное питания, и регулярные занятия спортом, больше времени проводить на свежем воздухе, отказаться от вредных привычек. Важно проходить регулярный медицинский осмотр.

Он поможет на ранней стадии выявить любую патологию или болезнь, которая может спровоцировать возникновение ишемического инсульта. Помимо этого, врач пропишет лекарственные препараты, которые будут оказывать профилактическое воздействие на сосуды, и препятствовать возникновению тромбов.

Ишемический инсульт – грозная патология, возникающая вследствие ослабления или полного прекращения кровообращения в одном из участков мозга. Самая частая причина такого состояния – закупорка (окклюзия) сосудов тромбом.

Для её устранения применяется тромболизис – введение специальных препаратов, растворяющих тромбы. О сути тромболитической терапии, её видах, особенностях проведения, показаниях и противопоказаниях и поговорим ниже.

Что такое тромболизис?

Как опасен инсульт – известно многим. Но далеко не все из нас знают, что исход болезни во многом зависит от правильности и своевременности оказания помощи. Дело в том, что клетки мозга не гибнут сразу. В зоне ядра ишемии они остаются жизнеспособными на протяжении 6-8 минут, а в прилегающих участках, называемых «ишемической полутенью», – 3-6 часов, а иногда и несколько суток. И если в этот период кровоток будет восстановлен, восстановят свои функции и нейроны.

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Тромболизис при инсульте призван разрушить тромботическую массу и возобновить движение крови по закупоренным мозговым сосудам. В основе действия методики – активация плазминогена крови и его перевод в плазмин. Именно этот фермент способствует разрыву поперечных связей между молекулами фибрина, обеспечивающими структурную целостность тромба.

Важнейшим фактором успешного тромболизиса при ишемическом инсульте является раннее лечение и правильное определение показаний к процедуре.

Показания к проведению при инсульте

Тромболизис может быть проведен только в следующих случаях:

  1. От появления первых признаков инсульта прошло не более четырех с половиной часов.
  2. КТ или МРТ подтвердило наличие именно ишемического инсульта. Это очень важный диагностический критерий, так как при развитии геморрагического инсульта, введение тромболитиков может привести к катастрофе.
  3. У больного нет противопоказаний к проведению процедуры.

Противопоказания

Процедура не проводится в случае, если у больного наблюдаются:

  • совсем незначительные проявления нарушения мозгового кровообращения или же – улучшение состояния;
  • систолическое АД выше 185 мм рт. ст., а диастолическое – выше 110 мм рт. ст.;
  • новообразования и абсцессы головного мозга;
  • кровоизлияния в мозговые ткани;
  • сосудистые мальформации;
  • повторные инсульты;
  • остановка сердца в последние 10 дней перед болезнью;
  • эпилептический припадок, предшествующий началу появления признаков инсульта;
  • проведение любых оперативных вмешательств (включая пункции органов) в течение последних 14 дней;
  • значительные ушибы головы и травмы свода черепа, произошедшие за 3 последних месяца;
  • беременность на любом сроке;
  • кормление грудью;
  • двухнедельный период после родов;
  • внутренние кровотечения за 20 дней до процедуры;
  • геморрагический диатез;
  • тяжелые патологии печени или почек;
  • уровень глюкозы в крови выше 22,2 ммоль/л и меньше 2,8 ммоль/л);
  • ухудшение коагуляционных свойств крови;
  • число тромбоцитов менее 100 000.

Особенности и виды тромболитической терапии

Процедуру лучше проводить в специализированном сосудистом отделении, в котором имеется блок интенсивной терапии или нейрореанимационное отделение. И при условии, что в клинике есть возможность сделать все необходимые анализы, КТ или МРТ в любое время дня и ночи. Для подтверждения факта окклюзии и уточнения месторасположения тромба рекомендуют сделать ТКДГ (транскраниальная допплерография). Полезен ТКДГ-мониторинг и после проведения процедуры, он позволит выявить возможные повторные закупорки сосудов.

Во время тромболизиса при инсульте каждые 15 минут контролируются динамика неврологического статуса. В последующем оценка состояния проводится с интервалом в один час. В течение первых двух часов от начала введения тромболитических препаратов каждые 15 минут пациенту измеряется АД (его показатели не должны быть выше 185/110). Последующее 6 часов контроль АД проводят с интервалом раз в полчаса, а в оставшееся время до конца суток – раз в час.

Мониторинг основных жизненно-важных функций осуществляется не менее 24-36 часов.

В современной медицине практикуют два способа введения тромболитиков – системный и селективный (локальный).

Системный метод тромболитической терапии при ишемическом инсульте подразумевает обычное внутривенное введение фермента. При этом препарат с кровотоком разносится по всем сосудам и растворяет все тромботические сгустки. Показанием к этой разновидности лечения становятся случаи, при которых у врача нет информации о местонахождении тромба, и когда с момента появления первых признаков заболевания прошло не более 4,5 часа.

К манипуляциям приступают только после полного диагностического обследования (включая КТ или МРТ) и осмотра неврологом. К сожалению, такая тщательная подготовка к тромболизису приводит к потере времени и уменьшает возможность восстановления еще не погибших клеток в зоне ишемической полутени, но недообследованность и введение препарата при геморрагическом инсульте или людям, имеющим противопоказания к процедуре, могут привести к очень тяжелым последствиям, включая смерть больного.

Поскольку восстановление кровотока может сопровождаться последующими кровоизлияниями, выбор метода терапии должен быть взвешенным и исходить от врача, специализирующегося на лечении инсультов.

Селективный тромболизис

Селективный метод более сложен, и он менее изучен. При этом методе лечения препарат вводится непосредственно к месту нахождения тромба, и выполняется только в том случае, когда невозможно выполнить внутривенный системный тромболизис.

Показанием к такому виду терапии могут стать тяжелые нарушения мозгового кровообращения, наступившие не позднее 6 часов до начала процедуры, а при ишемии в вертебро-базилярном бассейне – до 12 часов.

Все необходимые манипуляции выполняются в операционной под церебральным ангиографическим контролем.

К основным преимуществам селективного тромболизиса при инсульте относят:

  • малоинвазивность;
  • относительная безопасность и точность проводимых действий;
  • меньшая доза препарата и меньший риск кровотечений из периферических сосудов;
  • возможность видеть процесс тромболиза на экране монитора.

Об эффективности тромболитической терапии свидетельствует восстановление кровотока в пораженной зоне.

Недостатки метода:

  • Небольшая доказательная база в рамках клинических исследований и рутинной клинической практики;
  • Поскольку метод чаще всего применятся, когда уже невозможно выполнить системный тромболизис, и большая часть пораженных клеток мозга уже не сможет восстановить свои функции, то в таких случаях не ожидается значительного положительного эффекта от терапии;
  • Метод находится вне официально утвержденных медицинских показаний к применению тромболитических препаратов;
  • Сложность метода – необходимо дополнительное специальное оборудование и обученного персонала
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