Thrombolytic therapy. Indications for thrombolytic therapy and the features of it

Thromb formation is one of the most common pathological phenomena in the human body, which should be timely. This process leads to many unfavorable consequences up to the death of a person. To get rid of him, the doctors can assign thrombolysis.

General information about thrombolesis

In the body of each person there is a natural process of thrombolysis. It is carried out with the help of special enzymes in the blood. But these substances are not able to fully cope with large blood clots. They are effective only if there are small thrombus.

As a result, the resulting large clots block the clearance of the vessel completely or partially. Because of this, blood circulation fails, which leads to starvation of the cells of the body and even their elimination. This phenomenon violates the functioning internal organs.

Therefore, the question arises, how to dissolve the thrombus? To solve this problem, artificial thrombolysis is used. The essence of the methodology is that the doctor introduces medicines in Vienna, which are intended for resorption blood bumps.

Thrombolytic treatment is carried out in two ways:

1. System. The peculiarity is that it is completely no matter where it is located blood clots. The medicine spreads throughout the body along with blood and eventually faces a thrombus, sinking it. But this method of thrombolysis has one minus - the need to use a large dosage of the medication, which is negatively reflected in the circulatory system.
2. Local. This method is characterized in that the drug is administered directly to that section where there is blood clots. The drug is supplied to the vessel with a catheter. This method is quite complicated, the execution is controlled by the X-ray apparatus.

Which method to give preference in the implementation of thrombolytic treatment, solves the attending physician for each patient individually.

Where is thrombolytic therapy? Treatment can be carried out both at home and after hospitalization. Urgent thrombolytic treatment is the most effective, as it has an advantage regarding the time. After all, the earlier to perform the procedure, the greater the chance of saving a person.

In this regard, hospital thrombolysis has a significant minus. It is prescribed only after the patient is fully examined. Therefore, the speed of therapy is lower, but it is possible to verify the presence of contraindications to the use of thrombolytic, which avoids many adverse complications.

Application of thrombolysis in stroke and infarction

The brain stroke is a dangerous pathology, which often leads to a fatal outcome. Even if a person survives, he is very difficult for recovery. After all, with the disease, the blood supply to the brain cells is overlap, which leads to an acute violation of the brain circulation (ONMK) and the elimination of tissues.

Thrombolysis in stroke helps prevent adverse effects. It quickly clears the thrombus and warns necrosis of braincases. At the same time, you need to have time to introduce the drug within 6 hours from the moment of signs of pathology.

The same thing happens with the heart attack of the heart muscle. The disease also arises due to blockage of the lumen of the artery thrombus. Often it is accompanied by thrombophlebitis. For myocardial fabrics do not died, thrombolytic treatment should be carried out. It allows you to eliminate acute coronary syndrome (OX), reduce the area of \u200b\u200bmuscle damage, preserve the function of the left ventricle, which shakes blood, and reduce the risk of developing complications and ensure stable heart performance.

When is thrombolytic treatment?

Indications for the conduct of thrombolysis are various diseases of the heart and vessels that combine such a phenomenon as thrombosis. These diseases include:

1. Stroke.
2. Myocardial infarction.
3. Tel - lung thromboembolism.
4. Blocking the deep veins cluster, peripheral arteries Or artificial prostheses located in vascular lumets.

The need for thrombolytic treatment is determined by the attending doctor after a patient survey.

Who can not be prescribed therapy?

Doctors distinguish several factors, if there are no thrombolytic therapy, it is impossible. If you prescribe treatment, without paying attention to contraindications, there is a high risk of developing complications.

It is forbidden to do thrombolysis with such pathologies:

1. Elevated blood pressure.
2. Diabetes.
3. Allergies for drugs used in the treatment process.
4. Damage to vessels.
5. Malignant tumors.
6. Blood blood clotting.
7. Renal or liver failure.
8. Diseases of digestive organs.
9. Diseases that are able to provoke bleeding, such as aneurysm.

In addition to pathological conditions, it is not allowed to carry out thrombolytic therapy to women who carry a child, as well as people who accept anticoagulants who have recently transferred the operation or in the last 2 weeks of the skull injury. Also contraindicated thrombolesis patients whose age is more than 75 years.

What do the thrombus dissolve?

The medicine has a huge amount of thrombolytic drugs. They are constantly being improved. Currently, there are the following varieties of medicines, characterized by the nature of the impact:

1. Natural enzymes. They are used only with the system of TLT. It is helped to restore fibrinolysis, there is a resolution effect on the thrombus. But drugs affect the entire body, which is fraught with the appearance of bleeding, the development of allergies. Therefore, they use them limited.
2. Means of genetic engineering. Restore the fibrinogen in the blood. Experate only on blood clots. They are distinguished by instantaneous dissolution in the blood, therefore apply them with caution.
3. Preparations of an improved group. Characterized by the fact that there are selectively and long period.
4. Combined medicines. Several medical facilities are included in their composition.

From all groups you can select several thrombolitics, which are most often used for thrombolysis. These include:

• "Streptokinaz". It has the lowest cost among all thrombolytic drugs. The minus of its use is that the person often has its intolerance, allergies and other unpleasant complications are developing.
• "Urokinz". Despite the fact that the price of this drug is higher than the previous one, the benefits of it are small. When using a medicine, additional use of "heparin" is required.
• "Tenctepleza". On sale has another name - "Metaliz". Injectable, the use of "heparin" and "aspirin" is required. The drug is able to cause bleeding.
• "Ansrerezlaza". Also has a high cost. The introduction of this tool can be carried out. When used, it is not necessary to introduce heparin to Vienna.
• "Althelza". An expensive medicine that has a highly efficient action. After its use, the survival rate of patients is significantly higher than when applying other means. However, the drug has serious side effects.
• "Aktilaza". The medication acts directly on the thrombus, does not cause severe blood dilution, which prevents the occurrence of hemorrhage.

In addition to thrombolitics during thrombosis, other means are used, for example, diuretics ("phytolysin"), anticoagulants ("heparin"), anti-aggregants ("aspirin"). Also to eliminate symptoms, improved blood circulation is allowed to further use folk remedies. In extreme cases resort to surgical intervention.

Appointment of operational or medical treatment A doctor is engaged in taking into account the state of the patient, the degree of development of pathology, the presence of concomitant diseases and other factors.

Possible complications

Thrombolysis is capable not only to save the patient, but also cause adverse effects. These include:

1. Bleeding. It occurs due to the deterioration of blood coagulation.
2. Allergic reaction. Manifests itself in the form of skin rashes, accompanied by itching and swelling.
3. Arrhythmia. Appears after the recovery of coronary blood flow.
4. Repeated manifestation of pain syndrome. With such a complication, administration of narcotic analgesics in Vienna is prescribed.
5. Lower arterial pressure. To eliminate this side effect, it suffices to stop the use of thrombolitics.

Efficiency of therapy

The effectiveness of thrombolytic pills and injections depends primarily on how timely therapy was carried out. The greatest effect is achieved if the introduction of the drug was carried out no later than 5 hours after the symptoms of pathology.

Unfortunately, it is not always possible to carry out thrombolysis during this time. The problem lies in that not in all medical institutions It is possible to use the procedure under consideration.

How effectively the therapy passed, you can learn using a survey. To do this, conduct magnetic resonance or computed tomography in the case of a stroke or coronary artwork with heart attack of the heart muscle. Diagnostics after thrombolysis shows the expansion of the lumen of the vessel and the destruction of the blood cloudy.

Thus, thrombolytic therapy is an effective way to eliminate blood clots. This technique gives us the answer to the question of how to dissolve other parts of the body. It helps to quickly achieve the resorption of blood clot and avoid the consequences dangerous to human life and health.

The dissolution and splitting of the thrombus is carried out using such a process as thrombolysis. It is carried out natural or artificial (medicated). In the first case, blood enzymes split small clots. Large thrombus can dissolve only under the influence of thrombolytic. Medicinal preparations for thrombolysis are prescribed by the attending physician when making consequences, in the treatment of cardiovascular diseases.

Thrombolytics - what is it?

Thrombolytic drugs are medicinal productsdissolving blood clots. They consist of fibrin threads, which are a rolled protein. The formation of a thrombus is part of the natural protection of the human body, intended for clogging mechanical damage to vessels during injuries. In a patient with predisposition to thrombosis, or with a combination of negative tomb factors, form in intact vessels. Constantly increasing, the thrombus partially overlaps the clearance of the vessel, breaks blood circulation in it.

If the thrombus completely overlaps the main artery, the physicians have only a few hours for the operation and rescue the patient's life.

Thrombolytics need to be distinguished from drugs with a similar effect aimed at preventing the progression of cardiovascular diseases. These drugs are designed for emergency dissolution of blood closet, they are injected directly in vascular system.

Fibrinolytic preparations are used for thrombosis of large-size clots, as well as for dissolving thrombus in weakened patients or in the elderly, when the body cannot separate the thrombus. Because of thrombosis, the condition of the circulation of various organs and oxygen fasting fabrics occurs. When separating the thrombus, it is broken and clocked vessels leading to vital important organs. As a result, embolism or thromboembolism arises.

The purpose of thrombolitics is the prerogative of the attending physician who will definitely take into account the testimony and contraindications to their application. Most often, drugs with thrombolytic effect are used in the treatment of thrombosis and thromboembolism.

Indications for thrombolytic therapy:

Stroke of brain vessels;

Pulmonary artery thromboembolism (TEL);

Trombosis of the main vessels in the pathologies of the cardiovascular system.

Thrombus may be formed even after successful surgery, or after severe injury. With complications of varicose veins, thrombophlebitis is developing - inflammatory process Vessel walls followed by thrombus formation. Turba Covarism is that for a long time They do not manifest themselves with noticeable symptoms. The patient discovers that it is seriously sick, only with a complete blockage of the vessel and a sharp deterioration of the state.

Absolute contraindications to the use of thrombolitics:

Pronounced nasal, gastrointestinal, urogenital bleeding, which occurred at the time of treatment, as well as within 2 preceding weeks before him.

Injury, injuries, operations that occurred during the 10 preceding days, if these cases relate to the dorsal or brain - the term increases to 2 months.

Hemorrhagic stroke that occurred during the last half of the year ..

Pathology of the circulatory system concerning blood clotting.

Increased blood pressure, not bought by drugs.

Low blood platelets.

Caution prescribed thrombolitics at next diseases and states:

Age over 75 years;

Trubolitical (fibrinolytic) preparations are medications capable of dissolving blood clots consisting of fibrin yarns that are converting protein. Thrombova is a natural process human organismSince it is blood clots that contribute to the blockage of mechanically damaged vessels with wounds. However, when influencing negative factors or predisposition, the frarb itself is formed in holistic veins and arteries. Gradually becoming more, the thrombus is first partially, and then completely closes the clearance of the vessel, preventing blood circulation.

With severe acute states when the thrombus is fully clogged by a large vessel, the doctors have only a few hours to carry out the operation and keep the patient life.

Thrombolytics should be distinguished from other drugs with similar action, which only prevent the progression of the cardiovascular disease leading to thrombosis. Also, these drugs are distinguished by the fact that they are means of emergency exposure and are introduced directly into the vascular system for rapid dissolution of the thrombus.

Fibrinolytic drugs are applied in cases where the human body cannot independently cope with thrombos due to weakening associated with older age, or due to a large size of a clock. Thrombosis is dangerous in that it can cause an ischemia of a particular organ - a condition in which blood circulation will be broken in it, in connection with which oxygen starvation will arise. Also, blood clots can break away and clog vein or artery leading to a vital organ. This state got the name of embolism or thromboembolism.

Indications and contraindications

Before you receive this or that means, you need to explore the testimony and contraindications that it possesses. In the case of thrombolitics, the attending physician is engaged in this, as they are released from pharmacies only by recipe. These drugs can be applied in several areas of medicine, but in most cases they are used for thrombosis and thromboembolism. Indications for thrombolytic therapy look like this:

• myocardial infarction;
• brain stroke;
• pulmonary artery thromboembolism (TEL);
• the formation of blood clots in surface or main vessels in various diseases of the cardiovascular system;
• thrombophlebitis.

Trombo may also arise after a serious injury or even a successful operation. With a protracted flow of varicose veins, thrombophlebitis can be formed - inflammation of the vascular wall, followed by the formation of a blood clot. The danger of thromboms is that they may not show symptoms of their existence for a long time, and the patient will notice a sharp deterioration in the state only with the complete blockage of the blood vessel.

The absolute contraindications for receiving thrombolitics are the following factors:

1. Serious bleeding, which is available both at the time of the intended administration of the medicine and for the two preceding weeks. This includes gastrointestinal bleeding, selection from urinary tractas well as large-scale nose bleeding. If you ignore this contraindication, they can increase up to a critical state - hemorrhagic shock.
2. Any injuries and operations produced during the preceding 10 days, in the case of interference on the head or spin of the brain, the limit period reaches 2 months.
3. Hemorrhagic stroke that occurred during the preceding 6 months.
4. Fine harvested blood pressure.
5. Diseases associated with violation of blood coagulation and increased risk of bleeding.
6. Suspicion of pancreatitis.
7. Reducing blood platelet levels.
8. The probability of developing pericarditis, aneurysms and aortic bundles.
9. Individual intolerance to preparations ( allergic reactions).

There are relative contraindications to thrombolytic therapy, that is, the restrictions in which the medicine should be prescribed with caution and only in cases where possible benefit exceeds potential harm. This group includes the following factors:

• chronic liver diseases, kidneys or heart;
• old age, especially older than 75 years;
• pregnancy;
• complicated diabetes;
• recent bone fractures;
• multiple burns;
• thrombolytic therapy conducted in the previous 9 months.

If the patient has any chronic disease Or individual complaints, it is necessary to report this to the doctor before the start of thrombolytic therapy. Also, the attending specialist should ask about the existing allergies on medicationsTo avoid complications.

Classification of thrombolitics and basic drugs

Acquaintance with fibrinolytic means and their application began in the middle of the last century. Since then, these drugs have gradually improved, and today, according to the mechanism, the thrombolytics are divided into 4 groups, which are also called generations. Despite the fact that new drugs are considered the most effective, old still apply with no less efficiency.

The first generation includes the so-called natural natural enzymes, these drugs are also called systemic. They contribute to the activation of natural processes that stimulate the natural reaction of the organism on the thrombus. The complexity of the use of such drugs is that they, firstly, can cause an anaphylactic shock, as alien proteins, and secondly, can cause bleeding, since they activate all the amount of blood enzyme. The most famous streptocinase, urocainase, streptodecadis and fibrinolysin are most well known.

The second generation of thrombolytic is created using genetic engineering and biotechnology. They allow to introduce intestinal stick bacteria the necessary genes, as a result of which the desired substance is synthesized. The difference between the first-generation drugs from the first is that only those enzymes that are localized directly at the injection site are involved. Thus, the means affect locally, and not systemically, which avoids some side effects. Alpowlaza, actilis and recombinant transokinase are mainly used.

The third generation is even more improved, since it was possible to achieve a longer action of active ingredients and their electoral impact directly on the thrombus. The most famous from the third generation of Teakteplase, Lanoteplaza and Retoveplase. The fourth generation includes combined drugswhich act even more quickly, accurately and long, an example can serve as plasminogen's urogase.

At the moment, the optimal solution in most cases is the use of second generation thrombolytics. Despite the fact that there are more modern and progressive drugs, the second generation has already been checked, all possible has been studied. side effects and complications. More "young" drugs are not yet perfect, they can unpredictably affect the specific organism.

Thrombolytic therapy for ischemic stroke, myocardial infarction and other diseases can be systemic or local. In the first case, the drug is introduced into a vein and is applied by blood flow throughout the network, while the delivery of active components to thrombus occurs significantly longer. Local administration is organized by the catheter, while the drug is administered directly to the blood clot, contributing to rapid thrombolesis.

Efficiency and complications

To find out whether it was possible to achieve the result of the treatment with thrombolitics, the doctor must appoint tool methods Surveys. Most often applied magnetic resonance tomography (MRI) and cT scan (CT). Also 1-2 hours after the introduction of the medicine is carried out coronary art. This is a method for studying the coronary arteries that feed the heart using X-ray radiation with a preliminary administration to a contrast vessel. Distinguish several degrees of efficiency:

• 0 - the contrast is not moving along a clouded vessel clogged;
• 1 - a small amount of contrasting substance passed through the thrombus;
• 2 - more than half of contrast passed through the tombstone;
• 3 - permeability is completely restored, the contrast moves along the circulatory network.

Not for all patients therapy with thrombolitics becomes effective, in some cases complications arise - allergic reactions, reduced pressure, bleeding, temperature increase. If such states occur, you cannot engage in self-medication, you need to consult a doctor.

Thrombolysis with ischemic stroke is the process of eliminating blood clots with special medical preparations. In addition, the procedure helps to restore the functioning of blood flow by a vessel, which was obviously blocked by a bloody clock.

Based on what moment the treatment begins with thrombolysis, the implementation methods are divided into two types:

1. Selective thrombolysis. The procedure takes place in the first six hours.
2. Non-selective type. It is carried out in the first three hours after there is a violation of the work of hemodynamics.

By type of access to the location of the bloody clot, the procedure is divided into two types such as:

• Systemic thrombolysis. In this case, medicines with thrombolytic effects fall into the body using intravenous effects. There is no need to clarify the specific localization of blood clot.
• Local thrombolesis. Preparations are placed extremely close to the location of the thrombus.

What drugs have the action

Thrombolytics, which use medical workers, are improved from year to year. They are divided into four types according to the method of impact on the body:

Natural enzymes of natural origin. Such thrombolitics are also called systemic. They are prescribed accordingly with systemic therapy. They are divided into streptokinase, streptokinase, urogase. They have an impact directed to the resumption of the fibrinolysis process, are able to transform plasminogen to plasmins.

It is worth noting that such an action does not end on the thrombe. In addition, allergies may appear, since the basis of the material is hemolytic streptococcus (if we are talking about streptocinas). Therefore, such drugs have limitations to use.

Means of genetic engineering and biotechnology drugs. The second name is the fibrin selective. These include Aldepslav and Actilis. They selectively resume the work of fibrinogen in the tombach and their tissues. Do not have the overall impact.

Advanced variety with selective and prolonged impact. These include Retoelase, Lanotelezlase.

Combined type medicines. These include plasminogen and urocinase.

Unfortunately, it is impossible to determine exactly which drugs are better. One of the most studied and analyzed groups is the one that includes genetic engineering. Other groups are distinguished by a narrow-controlled effect for specific cases.

However, based on the speed of lysis, they have the greatest speed, rather than drugs of natural origin. Doctors relate to them with extreme caution, as they cause multiple complications.

Indications

Let's talk about general testimony for thrombolysis. They are combined by various pathologies of vessels with the formation of thrombus, which lead to changes in the internal organs. In order to preserve the life of the patient, such diagnoses are most important as:

• acute heart attack;
• thromboembolia;
• ischemic type stroke;
• shunt lock;
• thromboembolia.

In order to start thrombolysis with myocardial infarction at that stage, when the patient is not yet placed in the hospital there is only one solution - if there is a need for long transportation of the patient.

• During the heart attack draw attention to such symptoms as:
  The pain that continues more than thirty minutes.
• Gais beam blockade on the left side.
• Manifestations of heart attack on ECG.
• Problems of light artery and pressure in it.

Ischemic stroke is different:

• Clinical symptoms in the form of paresis, paralysis, problems with vision and speech.
• Symptoms of neurological type, which is determined by a neurologist.
• There is no response of the body to enter it drugs that expand the vessels.

Based on the instruction, it can be concluded that patients with TELL and increased risk of death have a mandatory testimony for thrombolysis, despite the fact that, in fact, the procedure is contraindicated. We are talking about such situations as the bleeding gastrointestinal, recent operations carried out within three weeks.

Contraindications

After the dissolution of blood clots occurs, new gastric bleeding can begin, uterine bleeding And other blood discharge, which happened in the patient over the past six months.

Contraindications of thrombolesis:

• The exacerbation of the diseases that are expressed by the presence of blood release.
• Recently transferred surgical interventions.
• The consequence of resuscitation activities over the past six months.
• Skull injuries up to two weeks.
• Problems with blood intake.
• Hypertension of arterial character.
• Use anticoagulants.
• Active gastric ulcer.
• Chronic diseases that have an impact on the spread of bloodstand (pancreatitis, aortic aneurysm, poor-quality tumors).

Contraindications for thrombolysis on such a criterion, like age, there are no thrombolysis. However, there is an upper limit, which is 75 years old.

If the patient has an allergic to the proposed drugs, it serves as a reason for the complete abandonment of thrombolysis. Special contraindications are present at TEL.

How to do?

The technique is carried out in two ways: locally and systemically. Thrombolysis under a stroke of a system type is characterized in that the drug is used even if there are no accurate data on the location of the bloody clock.

Together with the bloodstream, the medication spreads throughout the body and dissolves the thrombus at any point. But in such a situation it is necessary to use the abundant dosage of the drug, which adds load on the blood current system.

With a local procedure, drugs are injected into the localization area of \u200b\u200bblood clot. The supply of the drug occurs through the catheter.

Plus such a method is low invasiveness, it can be used even in the presence of complex chronic ailments in a patient.

According to international standards, the time of time from the moment of the patient's receipt to the hospital before the introduction of the medication should be equal to one hour.

This is the longest time to have medicines for diagnosing and counseling. Only with coordinated work, doctors can meet in such a period.
Doctors must comply with such treatment rules as:

• If necessary, the patient is put by the blade catheter or the probe. This procedure is carried out to thrombolysis. Since the use of medicines, any injury to the mucous membrane can lead to an increase in bleeding.
• It is not necessary to conduct an intramuscular injection procedure.
• You can not use a catheter for large veins on the first twenty-four hours after the procedure.
  Such norms are the same in both TEL and in strokes and infarction.

The drug has its own optimal dose, which is calculated on the basis of the patient's weight. Usually the inkjet method is introduced about ten percent of the entire dose, further, drip through the remnants of the drug for one hour.

Do not use other drugs along with thrombolysis. Sometimes it is recommended to prescribe respiration using a moistened oxygen mixture.

Monitor patient control is carried out during the day. The patient controls such indicators as:

• blood pressure;
• pulse and breathing, their frequency;
• body temperature.

Probable complications

Thrombolytic therapy for ischemic stroke, myocardial infarction and at Tel gives some complications, we offer you a list of the most common of them:

• Intensive bleeding, during which the level of hemoglobin and platelets is significantly reduced.
• Small bleeding, for example, from dysen or near the wound, which is located on the site of the introduction of the catheter.
• Increased body temperature, trembling in the body.
• Hypotension is a decrease in pressure. The reason is the impact of streptocinase.
• A rash may appear on the skin. If the case is hard, then the corticosteroids will appoint.
  Based on probable complications, you can establish clear contraindications for thrombolysis.

Evaluation of the effectiveness of treatment

The result and efficacy after treatment with thrombolysis is evaluated based on the results of the MRI and CT of the human brain, if we are talking about stroke. After a heart attack, it is necessary to carry out a coronary frame and learn about the power of pain - it should decrease.

Coronaryography is carried out after a half hours after thrombolysis. It makes it possible to slowly restore the bandwidth of the vessel through the blood clot. The formation of a thrombus continues, but it is worth noting that there is a decay.

Doctors have developed a score of the degree of treatment efficiency:

0 - Contrasts can not go through the place blocked by a blood clot.
1 - the contrasts of scarce penetrate the thrombus.
2 - a slow, but noticeable blood flow appears.
3 - the vascular channel is completely filled with blood, the vessel's permeability is restored.

Now you know what thrombolysis is. The problem of thrombolytic treatment is one of the prevailing problems in the field of modern health.

However, the conduct of such a procedure even taking into account limited conditions makes it possible to reduce death from infarction at fifty percent (when taking into account therapy in the first hour).

When treating treatment in the first three hours, the likelihood of death is reduced by twenty-five percent. That is why leading medical researchers from around the world are puzzled by the development of a tablet preparation, which could be used at home.

Wide segments should be aware that with a sudden skeletal of the face, the appearance of weakness or numbness of the limbs on one half of the body or violations of speech, that is, with suddenly arising symptoms of ischemic stroke, they should immediately call " ambulance"And insist on hospitalization into a specialized stroke center (or to a hospital with a neurosistribution department), where there is the possibility of carrying thrombolysis in the conditions of the Chamber / Block of intensive therapy. If less than 6 hours and the patient's condition passed from the beginning of the disease, the arrived brigade, as a rule, should not be carried out, trying to deliver a patient to the hospital as soon as possible, by taking a stroke team along the way.

By definition of the World Health Organization (or WHO), the stroke is a rapidly developing focal or global violation of the brain function, which is located more than 24 hours or leading to death, with the exclusion of another cause of the disease. The concept of ischemic stroke reflects the fact of developing the disease due to a decrease in blood flow in a certain zone of the brain and characterized by the formation of the brain infarction. The brain infarction is a necrosis zone formed due to persistent metabolic disorders arising from the insufficient blood supply to the brain section.

Despite the diversity of approaches used in the treatment of patients with ischemic strokes (AI), only five provisions have a high class (I) and the level of evidence (A) regarding the impact on the disease forecast: [ 1 ] emergency hospitalization patients with suspicion of strokes in hospitals with separations for the treatment of patients with acute violations of cerebral circulation (ONMK); [ 2 ] Purpose of drugs acetylsalicylic acid In the first 48 hours since the appearance of the first symptoms of the disease; [ 3 ] Conducting systemic thrombizisis by recombinant plasminogen tissue activator (RTPA) carefully selected patients in the first 4.5 h (one of the most effective methods drug treatment AI); [ 4 ] Performance of mechanical extraction of blood cloth using retriever stents in the first 6 h stroke patients with confirmed occlusion internal sleepy artery (BCA) or proximal segments (segment M1) of the middle cerebral artery (SMA); [ 5 ] Decompressive hemicrantectomy for the treatment of brain edema with occlusion of the main SMA trunk during the first 48 hours.

« Gold standard» Reperfusion therapy with AI remains systemic thrombolysis. Thus, in the case of consideration of the possibility of performing endovascular reperfusion methods of treatment (see below) in patients, relevant to the criteria for conducting systemic thrombolysis, it is necessary to carry out it, according to the North American recommendations for the treatment of acute stroke.

The systemic thrombolysis method was approved by the Federal Service for Supervision in Health and Social Development as a new medical technology (permission to apply New Medical Technology FS No. 2008/169 dated August 01, 2008). Since 2008, thrombolysis has been an integral component of the provision medical care Patients with stroke under the conditions of primary vascular offices and regional vascular centers created as part of the implementation of a set of measures to reduce mortality from vascular diseases. The order of thrombolytic therapy (TLT) is regulated by the Order of the Ministry of Health of the Russian Federation "On approval of the procedure for providing medical care patients with ONMK" No. 389n dated 06.07.2009 (as amended by the orders of the Ministry of Health of the Russian Federation No. 44n dated 02.02.2010 and No. 357n dated 04.27.2011), by order Ministry of Health of the Russian Federation No. 928n dated November 15, 2012 "On approval of the procedure for providing medical care patients with acute violations of cerebral circulation". In 2014, the All-Russian Society of Neurologists approved domestic Clinical recommendations In carrying out TLT with ischemic stroke.

The use of early TLT with ischemic stroke is based on the concept that the rapid (within a few hours) is restored to the circulation in the affected pool during the reconnaissance of the occlusive intracranial artery retains reversible damaged brain tissue in the ischemic "penumbra" zone (Penumbra), since it is maintained in it cerebral cells Viability for another 3 - 6 hours (ischemic "half-day" or Penumbra - a portion of brain tissue with critical blood flow around a necrosis focus, the latter also refers to the "core" of ischemic stroke).

Ischemic stroke - dynamic process. Ischemic stroke is a pathophysiological process, starting with a vessel blockage and ending with the formation of a brain infarction. As soon as the blood flow in the brain artery pool decreases to a level of less than 40% of the normal (below 20-5 ml per 100 g of brain substance per minute), neurons cease to function normally and focal symptoms appear. At the same time, there is damage to the brain tissue: almost 2 million neurons die without treatment, 14 billion synapses and more than 12 km of myelinized fibers are damaged. The average infarct volume is 54 cm3, it is formed on average for 10 hours (Saver J. L., 2006). From the 80s. Last century, we know that only a certain brain area, where perfusion is below 8 - 12 ml / 100 g / min (ischemic kernel), it receives irreversible damage in the first minutes. It is usually located, as a rule, large in the volume of the zone (ischemic half, or fuzzy), where the function of neurons is broken, but their structural integrity and recovery ability remains. Until recently, the ischemic kernel and Penumbro was made to portray as a chart on which one region simply surrounds the other (Fig. A). However, in most patients, the brain sections in the zone of ischemia are not homogeneous. Fig. B illustrates the concept of the development of ischemic stroke based on the positron-emission tomography, when the "islands" of hypoperfusion are located around the central kernel, including areas with very low bloodstream, characteristic of the ischemic nucleus (Lyden P. D., 2001). The bloodstream in the semi-sustained zone is inconsistent and depends on the level of collateral blood supply provided by the pillars of large arteries. Fate Penumbra depends on the level of blood flow and the duration of hypoperfusion. No interventions will help restore irreversible damaged neurons. At the same time, timely (within the so-called "therapeutic window"), blood supply reduction makes it possible to save and subsequently restore the activity of a significant part of viable cells, which means a decrease in the size of the brain infarction and the severity of the neurological deficit. The only way of reperfusion having a clinical significance is the resumption of blood flow in an occlusive vessel. Recanalization has a strong direct connection with the probability of a good outcome for ischemic stroke.

read also [1 ] Article: "Penumbra visualization methods for ischemic stroke" M.Yu. Maksimova, D.M., Professor, Nov.S. separation of brain circulation disorders with intensive care chambers; D.Z. Koroskova, neurologist, graduate student; M.V. Krotenkova, D.N., Head of the Department of Radiation Diagnostics of the Federal State Budgetary Institution "Scientific Center of Neurology" Ramna (Journal "Journal of X-ray and Radiology" No. 6, 2013) [Read] and [ 2 ] Dissertation for the degree of Ph.D. Ph.D. "Clinical and tomographic markers that determine the course of the acute period of brain infarction in the aircraft pool of the carotid system» D.Z. Koroskova, FGBU "Scientific Center of Neurology" RAM; Moscow, 2014 (p. 22 - 28) [read]

reference Information:

read more in the article "The results of the implementation of the standardization of the process of hospitalization of patients with an acute violation of cerebral circulation in the regional vascular center" P.G. Shnyakin, E.E. Korchagin, N.M. Nikolaeva, I.S. Usatova, S.V. Dranihnikov (Magazine "Nervous Diseases" №1, 2017) [read]

TLT should be carried out only if the diagnosis is made by a doctor who specializes in the management of patients with stroke, i.e., has experience in interpreting the results of neurovalization, since patients in the 6-hour "therapeutic window" have readings to thrombolesis are specified by magnetically -re-resonant tomography (MRI) in diffusion and perfusion mode, or, as an alternative, using computed tomography (CT). It should be emphasized that modern methods of neurovalization (CT and MR-angiography, CT and MRI perfusion) with minimal risk for the patient make it possible to objectify both occlusion of the artery that led to the development of ischemic stroke and achieved in the process of thrombolysis process.

CT and MRI in the diagnosis of brain infarction [to read ]

read also an article "Sequence-specific MRI signs that will help set the date of ischemic stroke» Laura M. Allen, MD; Anton N. Hasso, MD; Jason Handwerker, MD; Hamed Farid, MD; Radiographics 2012; 32: 1285-1297; DOI: 10.1148 / RG.325115760 [read]

read also post: Perfusion computed tomography (to the website)

CT remains the method of choice when examining candidates for thrombolysis. The benefits of the method should include the minimum duration of the study, availability, the ability to visualize the brain infarction in the first minutes and hours when applying contrasting techniques, quickly differentiate a ischemic stroke from a hemorrhagic stroke, to reliably diagnose intracranial hemorrhage, eliminate other diseases that imitate ischemic stroke (for example, tumors, Encephalites, arteriovenous malformations). Direct signs of the brain infarction appear on non-sensitive CT by the end of the first day from the beginning of the development of symptoms of stroke. An early CT-signs of ischemic stroke include a symptom of a hyperend artery (increase in density), the loss of the island is the blurring of the borders and the loss of normal outlines of Nucleus Lentiformis, compression (smoothing of subarachnoid spaces), the loss of differentiation on the gray and white substance in the ischemia zone.

In addition to the presence of the 4,5-hour "therapeutic window" (for system TLT) and data of neurovalization data for thrombolysis, it is necessary to evaluate the severity of neurological symptoms in the acute period of ischemic stroke on the NiHSS scale (National Institutes of Health Stroke Scale), which allows you to objectively approach A patient with stroke (valuation of the assessment increases, if an assessment is carried out in dynamics: one hour after thrombolysis, then every 8 hours during the first days). The total score on the scale makes it possible to approximately determine the forecast of the disease, which is of fundamental importance for planning TLT and control its effectiveness. Thus, the indication for trromasis is the presence of a neurological deficit (according to various data, more than 3 - 5 points on the NiHSS scale) involving the development of disability. The heavy neurological deficit (according to various data more than 24 - 25 points on the NiHSS scale) is a contraindication to the conduct of thrombolysis and does not have a significant impact on the outcome of the disease [cm. Nihss scale ].

about how to fill in the severity scale of the US National Institutions (Nihss.) You can read in an elective course "Introduction to angiooreurology", 16th occupation "Neurological and rehabilitation scales in angiooremology: a stroke scale of the US National Institute of Health, Renkin Scale, Rivermid scale and Bartel's index, Glasgow's scale; Shmonin A.A.; First St. Petersburg State Medical University. Acad. I.P. Pavlova, Department of Neurology and Neuro Surgery with the Clinic; St. Petersburg, 2014 - 2015 [read];

more detailed instructions for filling the NiHSS scale You can get from the book "Clinical recommendations for conducting patients with ischemic strokes and transient ischemic attacks" (library of a practical doctor, a series "Neurology") edited by prof. L.V. Stakhovskaya, Moscow, 2017

Candidates for holding [systemic] thrombizisis are patients aged 18 - 80 years, who have a clearly recorded the appearance of symptoms of stroke (in cases where the stroke develops during a night sleep or in the absence of an eyewitness, the time began to consider the moment when the patient is the last time Observed asymptomatic), with a source assessment on the Nihss scale ≥5 points. Mandatory conditions: no signs intracranial hemorrhage According to the results of CT or MRI [see contraindications For thrombolysis], the presence of a "therapeutic window" (time from the appearance of the first symptoms of the disease until the start of treatment does not exceed 4.5 hours), obtaining informed consent of the patient or relatives to perform manipulation.

note! A significant achievement of the last 10 years is the expansion of the therapeutic capabilities window from 3 to 4.5 hours. However, the TLT is symptomatic, since the target of its impact is only a thrombus or embball, which caused the blockage of one or another intra-or extracerebral artery, and not the source of thrombosis (Trombus in the left atrium ear, "unstable" atherosclerotic plaque, etc.). This caused a high percentage (20 - 34) early reocclusion and retrose, even after successfully completed thrombolesis (Source: Article "Stroke: Evaluation of the problem (15 years later)" M. Yu. Maksimova et al., FGBU "Scientific Center neurology" RAMS, Moscow; Magazine of neurology and psychiatry. S.S. Korsakov. 2014; 114 (11): 5-13).

The following types of thrombolysis are: Systemic (Sin.: Intravenous), selective (XI.: Intaartaurial, regional cathethaper), thrombolysis using mechanical devices for recanalization (aspiration catheter, Penumbra, Catch, Merci Retrieval System, Ultrasound Destruction of thromba and etc.), combined (intravenous + intraarterial; intraarterial + mechanical). With systemic (intravenous) thrombolesis as a thrombolytic is used by the recombinant fabric fibrinogen activator (RT-PA) [Althelza, the preparation of the actilization] at a dose of 0.9 mg \\ kg of the patient's body mass, 10% of the drug is administered intravenously, the remaining dose of intravenously drip during 60 minutes as early as possible. General analysis The data regarding the use of RTPA inside the 6-hour "window" shows that thrombolesis is effective for at least 4.5 hours, and potentially up to 6 hours after the start of ischemic stroke.

The diagram of fibrinolysis and the effect of certain fibrinolytic drugs
Clinical protocol of diagnosis and treatment of thrombolesis with ischemic stroke (2014) [read]; Recommendations for trombolytic therapy in patients with ischemic stroke (2014) [read]; Guide for doctors "Antitrombotic therapy with ischemic stroke" edited by Academician Ramn Shevchenko Yu.L. (library of the National Medical and Surgery Center named after N.I. Pirogov of the Ministry of Health of the Russian Federation) [read]

Selective thrombolesis is a minimally invasive method of delivering a thrombolytic preparation under X-ray control directly to Trombus using an endovascular catheter used for complete or partial restoration of the thrombown vessel portion. Selective thrombolysis is shown to patients with occlusion of proximal segments of intracerebral arteries. The use of intraarterial thrombolysis involves the patient's stay in a stroke center high level With round-the-clock access to cerebral angiography. Intiariter thrombolesis is a method of choice in patients with severe ischemic stroke up to 6 hours, with a stroke in the vertebro-basilar basin to 12 hours. With intraartiaric thrombolesis, a local long-term trombolytic infusion (RT-PA or UrCinza) is performed as much as possible for 2 hours under angiographic control.

The methodology of selective thrombolysis has a number of significant advantages over systemic thrombolysis: first, it helps to clarify the localization of occlusion, its nature, to find out the individual peculiarities of the brain circulation; secondly, significantly reduces the dose of the fibrinolytic drug and thereby reduces the risk of hemorrhagic complications; Third, it provides an opportunity for additional mechanical impact on Trombus, using a microchetteer or conductor for this; Fourth, it can be carried out outside the 3-hour time window, and, finally, the presence of a catheter in the affected artery allows you to control the flow of lysis thrombus and recovery of circulation using fractional angiography.

Clinical Protocol of Operational and Diagnostic Intervention: Regional Catheter (selective) thrombolesis (2015) [Read]

Currently, a mechanical recanalization of the affected area of \u200b\u200bartery using special tools - thromboemballtomy is currently more effective compared to intraarterial thrombolysis. This operational intervention Performed in radiotherapy conditions. The advantages of thromboembolectomy are minimizing the risk of systemic hemorrhagic complications and the possibility of impact on thrombus or embol after unsuccessful intravenous thrombolysis. To date, research results with such devices such as Merci, Penumbra and Catch are published.

Clinical Protocol of Operational and Diagnostic Intervention: endovascular treatment of ischemic stroke in the most acute period (2015) [read]

Currently, the TTT of ischemic stroke can be used in the damage to the arteries of both carotid and vertebobasilar pools. Nevertheless, all currently existing leadership guidelines are focused primarily on a vascular catastrophe in a carotid basin, primarily a medium cerebral artery; This is primarily due to the presence of obvious neurological deficit in such patients in the form of coarse paresis and sensitivity disorders. A typical functional deficiency in a patient with a heart attack in the rear brain artery pool (SMA) in the sharpest period is not always regarded by a doctor as a disabled. The assessment of the neurological deficit on a stroke scale of the National Institute of Health (NIHSS), which is one of the criteria for selecting patients for the TLT, is usually unable to fully reflect the severity of the patient's condition with a heart attack in the vertebrobasilar basin. In relation to an isolated defect of visual fields in an acute infarction in the ZMA basin, there are no recommendations at all. Therefore, TLT in patients with heart attacks in the SMA basin is not widely used. However, given that hemiparesis in some cases is a significant clinical component of heart attacks in the SMA basin, such patients, in the absence of contraindications, systemic and / or intraarterial (selective) thrombolysis is reasonably conducted. When comparing the profiles of the effectiveness and safety of intravenous thrombolysis, conducted during the first three hours from the appearance of symptoms, in patients with infarction in the carotid pool and infarction in the Pool of the ZMA significant difference in safety and the outcome of treatment was not found. At the same time, according to a number of authors, when conducting an intravenous TLT with ischemic lesions in the vertebobasilar basin, and in particular, the SMA, it is possible to expand the therapeutic window to 6.5 - 7 hours and even more compared to 4.5 hours with heart attacks in the carotid pool . Conducting intraarterial thrombolysis in the occlusion of the middle brain artery is recommended for no later than 6 hours from the beginning of the symptoms, with occlusion of the main artery - no later than 12 hours. At the same time, today there are no clear recommendations for the time limits when conducting intraarterial thrombolysis in patients with the defeat of the SMA ( a source: article "Ischemic stroke in the rear brain arteries basin: problems of diagnosis, treatment" I.A. Khasanov (doctor of the neurological department for patients with acute violations of cerebral circulation), E.I. Bogdanov; Republican clinical hospital MZ RT, Kazan; Kazan State Medical University (2013) [read] or [read]).

During thrombolysis and after its completion, intensive observation should be carried out (monitoring hell, pulse, frequency respiratory movements, body temperature and neurological status: the magnitudes of pupils, photoreacts, muscle strength and the volume of active movements in the limbs) in accordance with the provisions of international and domestic protocols [during thrombolysis - every 15 minutes; After the injection of thrombolitics: the first 6 hours - every 30 minutes; up to 24 hours - every 60 minutes]. After a day after thrombolysis, re-neurovalization (MRI / CT) is required.

Since thrombolysis (that is, the use of thrombolytic drugs) is accompanied by risk of extensive bleeding, potential advantages and possible risks Thrombolysis should be discussed with the patient and his family before the start of treatment is always when possible.

The following types of bleeding associated with the TLT are distinguished: small bleeding (usually due to puncture or damage to blood vessels, of gums), large bleeding (central nervous system, in the gastrointestinal or urogenital tract, in the retroperitoneal space, or bleeding from parenchymal organs). Before the procedure of thrombolysis and during the day after it, with the aim of preventing bleeding should not be performed intramuscular injections. If necessary, the installation of the blade, the nastastric probe is advisable to perform data of manipulations to thrombolysis, since otherwise there is a risk of bleeding from injured mucous membranes. The catheterization of the central noncommmable veins (connectible, jugular) is prohibited during the day after thrombolysis. It is not recommended to feed patients after thrombolysis for 24 hours. Antithrombotic therapy within secondary prophylaxis It is possible to start only 24 hours after intravenous TLT.

In case, during (or after), the patient has strong headaches, acute rise of blood pressure, nausea and vomiting, psychomotor excitation, vegetative symptoms (hyperemia of the face and scler, hyperhydrosis), a significant increase in focal neurological symptoms, which may indicate About development, tromboic infusion stops (if it is still ongoing) and urgent CT is performed. In the case of verification of signs of hemorrhagic transformation, the cerebral infarction zone is introduced by the introduction of freshly frozen plasma. When local hemorrhages occur (from the injection or gums [Symptom of the Vampire Smile]), the termination of the thrombizis procedure is not required, the bleeding stop is possible by pressed.

The hemorrhagic transformation of the focus of brain damage is syptomic if its development leads to an increase in the total score on the Nihss stroke scale for 4 or more points. In most cases, intracerebral hemorrhages after thrombizisis register the formation of asymptomic hemorrhagic transformation, detected by CT / MRI methods, which often accompanies clinical improvement and is evidence of reperfusion.

In the patient undergoing ischemic stroke, the main criteria for the effectiveness of thrombolysis are: full stabilization of vital functions (breathing, central hemodynamics, oxygenation, water-electrolyte balance, carbohydrate exchange), lack of neurological complications (brain swelling, convulsive syndrome, acute occlusal hydrocephalus, hemorrhage in the infarction zone, dislocation), minimizing the neurological deficit (ideally - restoration of everyday independence and by ability to work), restoring blood flow of the prozed [occlusive] vessel (confirmed by the results of angiographic and ultrasound Research), the lack of somatic complications (pneumonia, tel, thromboembolism of deep veins of the lower extremities, breakdowns, peptic ulcers, urinary tract infections, etc.), normalization of the level of blood pressure, etc.