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Introducere:
Accidentul vascular cerebral(AVC) reprezinta o cauza majora de disabilitate a
adultului cu numeroase implicatii bio-psiho-sociale. Exceptand patologia neurologica
caracteristica, pot exista o serie de complicatii care daca sunt neglijate compromit
succesul reabilitarii medicale si reintegrarea pacientului in societate. Disabilitatile pe
termen scurt si lung ce pot aparea sunt fizice, cognitive, emotionale si sociale.
Tulburarile cognitive si dementa sunt consecinte frecvente al AVC 1 si ambele sunt
asociate cu o calitate redusa a vietii si o utilizare crescuta a resurselor sanitare.
Dementa este o provocare international semnificativa , iar gestionare si prevenirea
AVC au fost identificate ca o cale esentiala pentru profilaxia tulburarilor cognitive si
a dementei.2
În 2017, Stroke Alliance for Europe (SAFE), împreună cu Organizația Europeană
pentru Accident Stroke (ESO), preconizeaza ca între 2015 și 2035, numărul
accidentelor vasculare cerebrale va crește cu 34% din cauza unui populatie
imbatranita3.
Material si metode:
Am efectuat un studiu prospectiv de 6 luni in Sectia de Neurologie a Spitalului de
urgent “Sf Apostol Andrei” ,Galati, in care am inclus un numar de 50 de pacienti, cu
varsta peste 60 de ani. In aceasta perioada am analizat corelatia intre AVC si
dementa si impactul acestora asupra programului de reabilitare in perioada post
acuta a AVC. Deasemnea am urmarit corelatia intre comorbiditatile pacientului si
1
Barbay M, Diouf M, Roussel M, Godefroy O; GRECOGVASC study group. Systematic review and meta-analysis of
prevalence in post-stroke neurocognitive disorders in hospital-based studies. Dement Geriatr Cogn Disord. 2018;46(5-
6):322–34.
2
Hachinski V, Einhäupl K, Ganten D, Alladi S, Brayne C, Stephan BC, et al. Preventing dementia by preventing stroke: the Berlin
Manifesto. Alzheimers Dement. 2019 Jul;15(7):961–84.
3
internet
influenta acestora asupra planului de recuperare in perioada imediata a AVC.Pe
parcursul celor 6 luni ,468 de pacienti au suferit un accident vascular cerebral ,
dintre acestia 86 au fost cu AVC hemoragic si 382 au fost cu AVC ischemic. Studiul
nostru a inclus doar pacientii care au corelat AVC si o forma de tulburare
neurocognitiva .
Rezultate si discutii.
Pe parcursul celor 6 luni, din cei 468 de pacienti cu AVC , 50 dintre acesti au
avut ca diagnostic secundar una din formele de tulburare neurocognitiva. Dintre
acestia x % au fost de sex masculin si y % de sex feminin , z din mediul rural si t din
mediul urban. De aici observandu-se predispozitia pentru sexul ? si mediul ?
Categoria tulburarilor neurocognitive cuprinde grupul de tulburari in care deficitul
clinic principal este la nivelul functiei cognitive si care deobicei sunt dobandite,
nefiind o tulburare de dezvoltare.4 TNC descrise in DSMV sunt delirium,
sindroamele de TNC majore, sindroamele de TNC usoare si subtipurile lor
etiologice. Aceste subtipuri pot fi clasificate luand in considerare mai multi factori:
evolutia in timp, domeniile afectate si simptomele asociate 5.In cazul TNC vasculara
etiologia poate varia de la un AVC produs la nivelul unui vas important pana la boala
microvasculara, leziunile putand fi focale, multifocale sau difuze, tabloul clinic variind
in functie de severitatea leziunii. Elementul central al TNC este declinul cognitiv,
dobandit in unul sau mai multe domenii cognitive, in forma majora ADL este mult
afectat iar in formele usoare pacientul declara ca are nevoie de un timp mai lung
pentru anumite activitati ,frecvent considerate normale in cazul varstnicilor.
PSD=poststroke dementia
VaD=vascular disease
VCI=vascular cognitive impairment
6
Cognitive and physical impairment and the risk of stroke – A prospective cohort study A. Heshmatollah, U. Mutlu, P.
J. Koudstaal, M. A. Ikram & M. K. Ikram,Scientific Reports volume 10, Article number: 6274 (2020)
8.Onyike C.U. Cerebrovascular disease and dementia. Int. Rev. Psychiatry. 2006;18:423–431
7
Ghid de recuperare AVC
8
LANDIS T. REGARD M.- Die neuropsihobenischen Folgen des Schaudel-Hirn Traumes und ihre Reabilitation ,by Sydney Licht, Ed.
Wawereley Press,USA, 351-353
9
SODERBACK I. –A house based assessment of intellectual functions in patiets with acquired brain damage –Scand. J.
REHAB.Med. 20, 57-69.
In ceea ce priveste tipul de AVC , cei cu forma ischemic au o rata de
supravietuie si de recuperare mai mare comparativ cu cei cu forma hemoragica,
ceea ce explica si aparitia sau agravarea unor tulburari neurocognitive mai mult in
cazul celor cu hemoragie10 .In studiul nostrum %(n=) au fost cu AVC hemoragic, %
(n=) AVC ischemic iar in ceea ce priveste deficitul motor % (n=) au prezentat
hemipareza si %(n=) hemiplegie ,dintre acestia un procent de % (n=) pe partea
dreapta si %(n=) pe partea stanga.
Concluzii:
10
11
Hebert D., Lindsay M. P., McIntyre A., et al. Canadian stroke best practice recommendations: Stroke rehabilitation practice
guidelines, update 2015. International Journal of Stroke. 2016;11(4):459–484. doi: 10.1177/1747493016643553. [PubMed]
[CrossRef] [Google Scholar]
12
Pendefunda L, Vlad T.-Recuperarea bolnavului hemiplegic adult- Ed. Contact International, Iasi ,pag.66-67.
Din grupul studiat numarul barbatilor afectati a fost mai mare , probabil ca urmare a
abuzului de alcool si tutun si a uzurii fizice.
!!! The hours of therapy vary across different inpatient rehabilitation settings. Generally,
most guidelines advocate minimum 45 minutes of each relevant therapy for at least 5 days a week
13
!! Poststroke cognitive impairment is common and can affect up to one-third of stroke survivors [ 10,
11]. However, subtle cognitive impairment may not appear apparent, especially when the stroke
survivor seems to have recovered functionally in other aspects [ 10, 11]. In most cases, these deficits are
persistent and usually have progressively worsened [ 12]. Poststroke cognitive impairment is also more
common in those with recurrent strokes [13]. It often coexists with other neuropsychological problems
including language disorders, fatigue, depression, and apathy [ 13]. The mechanisms of poststroke
cognitive impairment could be either directly due to cerebral vascular injury or indirectly due to an
associated asymptomatic Alzheimer pathology or white matter changes from small vessel disease [ 14].
Factors independently associated with dementia in stroke survivors include atrial fibrillation, previous
stroke, myocardial infarction, hypertension, diabetes mellitus, and previous transient ischemic attack
[15]. The combined motor and cognitive impairments significantly increase risks of long term
functional disability and increase healthcare cost as reflected by an increase in hospital readmission
rates and mortality rates [16].
Cognitive impairment which occurs either as a prestroke condition or a poststroke is often significantly
correlated with reduced functional gains and poor rehabilitation outcomes in elderly patients. A local
study by Kong et al. showed that 45% of elderly stroke patients (≥75 years old) admitted to a
rehabilitation facility had cognitive impairment and cognition scores strongly predicted functional
outcomes [42]. Studies reported evidence of significant impairment of basic and instrumental ADLs in
poststroke cognitively impaired elderly survivors [43, 44]. Another study by Pasquini et al. concluded
that cognitive impairment (preexisting or new) together with age was the most important predictor of
institutionalization 3 years after stroke [45]. Prestroke dementia has been shown to increase risk of 6-
month and delayed poststroke mortality [46]. However, elderly stroke patients with cognitive
impairments could still benefit from rehabilitation
13
Hebert D., Lindsay M. P., McIntyre A., et al. Canadian stroke best practice recommendations: Stroke rehabilitation practice
guidelines, update 2015. International Journal of Stroke. 2016;11(4):459–484. doi: 10.1177/1747493016643553. [PubMed]
[CrossRef] [Google Scholar]