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Лечение пациентов с сосудистой патологией головного мозга: некоторые решения сложной задачи
Янишевский С.Н. Лечение пациентов с сосудистой патологией головного мозга: некоторые решения сложной задачи. Справочник поликлинического врача. 2017; 6: 52–56.
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Yanishevsky S.N. Treatment of patients with cerebral vascular pathology: some solutions to a complex problem. Handbook for Practitioners Doctors. 2017; 6: 52–56.
Материалы доступны только для специалистов сферы здравоохранения. Авторизуйтесь или зарегистрируйтесь.
Аннотация
Лечение пациента с сосудистой патологией головного мозга представляет собой непростую задачу. Несмотря на очевидные успехи фармакологии, число острых нарушений мозгового кровообращения остается на прежнем уровне, а число диагностируемых осложнений хронических нарушений мозгового кровообращения неуклонно нарастает. Основная задача врача при выборе стратегии и тактики лечения таких пациентов – поддержание нормального метаболизма мозговой ткани и профилактика ишемических повреждений головного мозга. И врач, и пациент часто сталкиваются с феноменом полипрагмазии, когда для достижения лечебных целей назначается большое количество препаратов. В статье описаны цели и задачи лечения пациентов с сосудистыми заболеваниями головного мозга, варианты использования препаратов, обладающих мультимодальным эффектом. Особое внимание уделено эффективности и безопасности антитромботической терапии.
Ключевые слова: сосудистые заболевания головного мозга, цереброваскулярная болезнь, инсульт, дисциркуляторная энцефалопатия, профилактика инсульта, антитромботическая терапия, комбинированная терапия.
Ключевые слова: сосудистые заболевания головного мозга, цереброваскулярная болезнь, инсульт, дисциркуляторная энцефалопатия, профилактика инсульта, антитромботическая терапия, комбинированная терапия.
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Treatment of a patient with vascular pathology of the brain is a difficult task. Despite the obvious success of pharmacology, the number of acute disorders of cerebral circulation remains at the same level, and the number of diagnosed complications of chronic circulatory disorders is steadily increasing. The main task of the doctor when choosing the strategy and tactics of treatment of such patients is maintenance of normal metabolism of brain tissue and prevention of ischemic brain damage. Both the doctor and the patient often face the phenomenon of polypharmacy, when a large number of drugs are prescribed to achieve therapeutic goals. The article describes the goals and objectives of treating patients with cerebrovascular diseases, the use of drugs that have a multimodal effect. Particular attention is paid to the effectiveness and safety of antithrombotic therapy.
Key words: vascular diseases of the brain, cerebrovascular diseases, stroke, dyscirculatory encephalopathy, stroke prevention, antithrombotic therapy, combined therapy.
Полный текст
Список литературы
1. Информационный бюллетень Всемирной организации здравоохранения, http://www.who.int/mediacentre/factsheets/fs310/ru/ / Informatsionnyi biulleten' Vsemirnoi organizatsii zdravookhraneniia, http://www.who.int/mediacentre/factsheets/fs310/ru/
[in Russian]
2. Гайкова О.Н. Морфологические проявления общепатологических процессов в нервной системе. Сопоставление данных посмертной МРТ, макро- и микроскопии. СПб: ВЕСЬ, 2015. / Gaikova O.N. Morfologicheskie proiavleniia obshchepatologicheskikh protsessov v nervnoi sisteme. Sopostavlenie dannykh posmertnoi MRT, makro- i mikroskopii. SPb: VES'', 2015. [in Russian]
3. Танашян М.М., Домашенко М.А. Дипиридамол в комплексной терапии хронических цереброваскулярных заболеваний. Нервные болезни. 2012; 3: 27–30. / Tanashian M.M., Domashenko M.A. Dipiridamol v kompleksnoi terapii khronicheskikh tserebrovaskuliarnykh zabolevanii. Nervnye bolezni. 2012; 3: 27–30. [in Russian]
4. Янишевский С.Н., Гайкова О.Н., Саруханов Т.М. и др. Особенности ремоделирования сосудов при сахарном диабете 2 типа и церебральной дегенеративно-дилатационной артериопатии. Рос. нейрохирургический журн. им. проф. А.Л.Поленова. 2013; V (1): 37–43. / Ianishevskii S.N., Gaikova O.N., Sarukhanov T.M. i dr. Osobennosti remodelirovaniia sosudov pri sakharnom diabete 2 tipa i tserebral'noi degenerativno-dilatatsionnoi arteriopatii. Ros. neirokhirurgicheskii zhurn. im. prof. A.L.Polenova. 2013; V (1): 37–43. [in Russian]
5. Balakumar P, Nyo YH, Renushia R et al. Classical and pleiotropic actions of dipyridamole: Not enough light to illuminate the dark tunnel? Pharmacol Res 2014; 87: 144–50.
6. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 2002; 287 (19): 2570–81.
7. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348 (9038): 1329–39.
8. Ciacciarelli M, Zerbinati C, Violi F, Iuliano L. Dipyridamole: a drug with unrecognized antioxidant activity. Curr Top Med Chem 2015; 15 (9): 822–9.
9. Dinner HC et al. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143 (1–2): 1–13.
10. Diener H-C et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364: 331–37.
11. Ernens I, Léonard F, Vausort M et al. Adenosine up-regulates vascular endothelial growth factor in human macrophages. Biochem Biophys Res Commun 2010; 392 (3): 351–6.
12. Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 1991; 54: 1044–54.
13. Feigin VL et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2014; 1: 245–54.
14. Galabov AS, Mastikova M. Dipyridamole induces interferon in man. Biomed Pharmacother 1984; 38: 412–3.
15. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25 (5): 457–507. DOI: 10.1159/000131083. Epub 2008 May 6.
16. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160–236.
17. Jefferson T, Tyrrel D. Antivirals for the common cold. The Cochrane Database of Systematic Reviews, Issue. Art. No.: CD002743. DOI: 10.1002/14651858. CD002743, 2004.
18. Johnson ES, Lanes SF, Wentworth CE et al. A meta-regression analysis of the dose-response effect of aspirin on stroke. Arch Intern Med 1999; 159: 1248–53.
19. Kyttaris VC, Zhang Zh, Kampagianni O, Tsokos GC. Calcium Signaling in Systemic Lupus Erythematosus T Cells A Treatment Target. Arthritis Rheum 2011; 63 (7): 2058–66.
20. Massaro M, Scoditti E, Carluccio MA et al. Dipyridamole decreases inflammatory metalloproteinase-9 expressionand release by human monocytes. Thromb Haemost 2013; 109. 280–9.
21. Fowler M. Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes 2008; 26: 77–82.
22. O’Donnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010; 376 (9735): 112–23. DOI: 10.1016/S0140-6736(10)60834-3.
23. Pattillo ChB, Fang K, Terracciano J, Kevil CG. Reperfusion of chronic tissue ischemia: nitrite and dipyridamole regulation of innate immune responses. Ann N Y Acad Sci 2010; 1207: 83–8.
24. Posner HB, Tang MX, Lushsinger J et al. The relationship of hypertension in the elderly to AD, vascular dementia, and cognitive function. Neurology 2002; 58 (8): 1175–81.
25. 2013 ESH/ESC Guidelines for the management of arterial hypertension. J Hypertens 2013; 31: 1281–357.
26. Atlas of International Diabetes Federation, http://www.diabetesatlas.org
2. Гайкова О.Н. Морфологические проявления общепатологических процессов в нервной системе. Сопоставление данных посмертной МРТ, макро- и микроскопии. СПб: ВЕСЬ, 2015. / Gaikova O.N. Morfologicheskie proiavleniia obshchepatologicheskikh protsessov v nervnoi sisteme. Sopostavlenie dannykh posmertnoi MRT, makro- i mikroskopii. SPb: VES'', 2015. [in Russian]
3. Танашян М.М., Домашенко М.А. Дипиридамол в комплексной терапии хронических цереброваскулярных заболеваний. Нервные болезни. 2012; 3: 27–30. / Tanashian M.M., Domashenko M.A. Dipiridamol v kompleksnoi terapii khronicheskikh tserebrovaskuliarnykh zabolevanii. Nervnye bolezni. 2012; 3: 27–30. [in Russian]
4. Янишевский С.Н., Гайкова О.Н., Саруханов Т.М. и др. Особенности ремоделирования сосудов при сахарном диабете 2 типа и церебральной дегенеративно-дилатационной артериопатии. Рос. нейрохирургический журн. им. проф. А.Л.Поленова. 2013; V (1): 37–43. / Ianishevskii S.N., Gaikova O.N., Sarukhanov T.M. i dr. Osobennosti remodelirovaniia sosudov pri sakharnom diabete 2 tipa i tserebral'noi degenerativno-dilatatsionnoi arteriopatii. Ros. neirokhirurgicheskii zhurn. im. prof. A.L.Polenova. 2013; V (1): 37–43. [in Russian]
5. Balakumar P, Nyo YH, Renushia R et al. Classical and pleiotropic actions of dipyridamole: Not enough light to illuminate the dark tunnel? Pharmacol Res 2014; 87: 144–50.
6. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 2002; 287 (19): 2570–81.
7. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348 (9038): 1329–39.
8. Ciacciarelli M, Zerbinati C, Violi F, Iuliano L. Dipyridamole: a drug with unrecognized antioxidant activity. Curr Top Med Chem 2015; 15 (9): 822–9.
9. Dinner HC et al. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143 (1–2): 1–13.
10. Diener H-C et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364: 331–37.
11. Ernens I, Léonard F, Vausort M et al. Adenosine up-regulates vascular endothelial growth factor in human macrophages. Biochem Biophys Res Commun 2010; 392 (3): 351–6.
12. Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 1991; 54: 1044–54.
13. Feigin VL et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2014; 1: 245–54.
14. Galabov AS, Mastikova M. Dipyridamole induces interferon in man. Biomed Pharmacother 1984; 38: 412–3.
15. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25 (5): 457–507. DOI: 10.1159/000131083. Epub 2008 May 6.
16. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160–236.
17. Jefferson T, Tyrrel D. Antivirals for the common cold. The Cochrane Database of Systematic Reviews, Issue. Art. No.: CD002743. DOI: 10.1002/14651858. CD002743, 2004.
18. Johnson ES, Lanes SF, Wentworth CE et al. A meta-regression analysis of the dose-response effect of aspirin on stroke. Arch Intern Med 1999; 159: 1248–53.
19. Kyttaris VC, Zhang Zh, Kampagianni O, Tsokos GC. Calcium Signaling in Systemic Lupus Erythematosus T Cells A Treatment Target. Arthritis Rheum 2011; 63 (7): 2058–66.
20. Massaro M, Scoditti E, Carluccio MA et al. Dipyridamole decreases inflammatory metalloproteinase-9 expressionand release by human monocytes. Thromb Haemost 2013; 109. 280–9.
21. Fowler M. Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes 2008; 26: 77–82.
22. O’Donnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010; 376 (9735): 112–23. DOI: 10.1016/S0140-6736(10)60834-3.
23. Pattillo ChB, Fang K, Terracciano J, Kevil CG. Reperfusion of chronic tissue ischemia: nitrite and dipyridamole regulation of innate immune responses. Ann N Y Acad Sci 2010; 1207: 83–8.
24. Posner HB, Tang MX, Lushsinger J et al. The relationship of hypertension in the elderly to AD, vascular dementia, and cognitive function. Neurology 2002; 58 (8): 1175–81.
25. 2013 ESH/ESC Guidelines for the management of arterial hypertension. J Hypertens 2013; 31: 1281–357.
26. Atlas of International Diabetes Federation, http://www.diabetesatlas.org
________________________________________________
1. Informatsionnyi biulleten' Vsemirnoi organizatsii zdravookhraneniia, http://www.who.int/mediacentre/factsheets/fs310/ru/
[in Russian]
2. Gaikova O.N. Morfologicheskie proiavleniia obshchepatologicheskikh protsessov v nervnoi sisteme. Sopostavlenie dannykh posmertnoi MRT, makro- i mikroskopii. SPb: VES'', 2015. [in Russian]
3. Tanashian M.M., Domashenko M.A. Dipiridamol v kompleksnoi terapii khronicheskikh tserebrovaskuliarnykh zabolevanii. Nervnye bolezni. 2012; 3: 27–30. [in Russian]
4. Ianishevskii S.N., Gaikova O.N., Sarukhanov T.M. i dr. Osobennosti remodelirovaniia sosudov pri sakharnom diabete 2 tipa i tserebral'noi degenerativno-dilatatsionnoi arteriopatii. Ros. neirokhirurgicheskii zhurn. im. prof. A.L.Polenova. 2013; V (1): 37–43. [in Russian]
5. Balakumar P, Nyo YH, Renushia R et al. Classical and pleiotropic actions of dipyridamole: Not enough light to illuminate the dark tunnel? Pharmacol Res 2014; 87: 144–50.
6. Beckman JA, Creager MA, Libby P. Diabetes and atherosclerosis: epidemiology, pathophysiology, and management. JAMA 2002; 287 (19): 2570–81.
7. CAPRIE Steering Committee. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348 (9038): 1329–39.
8. Ciacciarelli M, Zerbinati C, Violi F, Iuliano L. Dipyridamole: a drug with unrecognized antioxidant activity. Curr Top Med Chem 2015; 15 (9): 822–9.
9. Dinner HC et al. European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. J Neurol Sci 1996; 143 (1–2): 1–13.
10. Diener H-C et al. Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial. Lancet 2004; 364: 331–37.
11. Ernens I, Léonard F, Vausort M et al. Adenosine up-regulates vascular endothelial growth factor in human macrophages. Biochem Biophys Res Commun 2010; 392 (3): 351–6.
12. Farrell B, Godwin J, Richards S, Warlow C. The United Kingdom transient ischaemic attack (UK-TIA) aspirin trial: final results. J Neurol Neurosurg Psychiatry 1991; 54: 1044–54.
13. Feigin VL et al. Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2014; 1: 245–54.
14. Galabov AS, Mastikova M. Dipyridamole induces interferon in man. Biomed Pharmacother 1984; 38: 412–3.
15. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasc Dis 2008; 25 (5): 457–507. DOI: 10.1159/000131083. Epub 2008 May 6.
16. Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2014; 45: 2160–236.
17. Jefferson T, Tyrrel D. Antivirals for the common cold. The Cochrane Database of Systematic Reviews, Issue. Art. No.: CD002743. DOI: 10.1002/14651858. CD002743, 2004.
18. Johnson ES, Lanes SF, Wentworth CE et al. A meta-regression analysis of the dose-response effect of aspirin on stroke. Arch Intern Med 1999; 159: 1248–53.
19. Kyttaris VC, Zhang Zh, Kampagianni O, Tsokos GC. Calcium Signaling in Systemic Lupus Erythematosus T Cells A Treatment Target. Arthritis Rheum 2011; 63 (7): 2058–66.
20. Massaro M, Scoditti E, Carluccio MA et al. Dipyridamole decreases inflammatory metalloproteinase-9 expressionand release by human monocytes. Thromb Haemost 2013; 109. 280–9.
21. Fowler M. Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes 2008; 26: 77–82.
22. O’Donnell MJ, Xavier D, Liu L et al. Risk factors for ischaemic and intracerebral haemorrhagic stroke in 22 countries (the INTERSTROKE study): a case-control study. Lancet 2010; 376 (9735): 112–23. DOI: 10.1016/S0140-6736(10)60834-3.
23. Pattillo ChB, Fang K, Terracciano J, Kevil CG. Reperfusion of chronic tissue ischemia: nitrite and dipyridamole regulation of innate immune responses. Ann N Y Acad Sci 2010; 1207: 83–8.
24. Posner HB, Tang MX, Lushsinger J et al. The relationship of hypertension in the elderly to AD, vascular dementia, and cognitive function. Neurology 2002; 58 (8): 1175–81.
25. 2013 ESH/ESC Guidelines for the management of arterial hypertension. J Hypertens 2013; 31: 1281–357.
26. Atlas of International Diabetes Federation, http://www.diabetesatlas.org
Авторы
С.Н.Янишевский
ФГБВОУ ВО «Военно-медицинская академия им. С.М.Кирова» Минобороны России. 194044, Россия, Санкт-Петербург, ул. Академика Лебедева, д. 6
stasya71@yandex.ru
ФГБВОУ ВО «Военно-медицинская академия им. С.М.Кирова» Минобороны России. 194044, Россия, Санкт-Петербург, ул. Академика Лебедева, д. 6
stasya71@yandex.ru
________________________________________________
S.N.Yanishevsky
S.M.Kirov Medical Military Academy of the Ministry of Defence of the Russian Federation. 194044, Russian Federation, Saint Petersburg, ul. Akademika Lebedeva, d. 6
stasya71@yandex.ru
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