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Лечение пациентов с сосудистой патологией головного мозга: некоторые решения сложной задачи
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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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.
Key words: vascular diseases of the brain, cerebrovascular diseases, stroke, dyscirculatory encephalopathy, stroke prevention, antithrombotic therapy, combined therapy.
Ключевые слова: сосудистые заболевания головного мозга, цереброваскулярная болезнь, инсульт, дисциркуляторная энцефалопатия, профилактика инсульта, антитромботическая терапия, комбинированная терапия.
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Key words: vascular diseases of the brain, cerebrovascular diseases, stroke, dyscirculatory encephalopathy, stroke prevention, antithrombotic therapy, combined therapy.
Полный текст
Список литературы
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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.
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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.
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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. 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
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. 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
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
ФГБВОУ ВО «Военно-медицинская академия им. С.М.Кирова» Минобороны России. 194044, Россия, Санкт-Петербург, ул. Академика Лебедева, д. 6
stasya71@yandex.ru
________________________________________________
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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