{"id":562,"date":"2024-02-07T23:51:38","date_gmt":"2024-02-07T20:51:38","guid":{"rendered":"https:\/\/tatd.org.tr\/geriatri\/?p=562"},"modified":"2024-02-07T23:51:39","modified_gmt":"2024-02-07T20:51:39","slug":"geriatrik-olguda-serebrovaskuler-olay-yonetimi","status":"publish","type":"post","link":"https:\/\/tatd.org.tr\/geriatri\/genel\/geriatrik-olguda-serebrovaskuler-olay-yonetimi\/","title":{"rendered":"Geriatrik Olguda Serebrovask\u00fcler Olay Y\u00f6netimi"},"content":{"rendered":"\n

Giri\u015f \/ Epidemiyoloji:<\/strong> Yirminci y\u00fczy\u0131l\u0131n ortalar\u0131ndan itibaren ya\u015fl\u0131 n\u00fcfus artmaya ba\u015flam\u0131\u015f ve bu art\u0131\u015f 21. y\u00fczy\u0131lda daha da fazlala\u015fm\u0131\u015ft\u0131r. D\u00fcnya\u2019da ve T\u00fcrkiye\u2019de ortalama ya\u015fam s\u00fcresi uzamakta ve ya\u015fl\u0131 n\u00fcfusun normal n\u00fcfusa oran\u0131 giderek artmaktad\u0131r. T\u00fcrkiye \u0130statistik Kurumu verilerine g\u00f6re 2017 y\u0131l\u0131nda %8,5 olan 65 ya\u015f ve \u00fcst\u00fc n\u00fcfusun t\u00fcm n\u00fcfusa oran\u0131, 2022 y\u0131l\u0131nda %9,9\u2019a y\u00fckseldi ve 2030 y\u0131l\u0131nda %12,9 olmas\u0131 beklenmektedir1<\/sup> (\u015eekil-1). Bu durum acil servis \u00e7al\u0131\u015fanlar\u0131n\u0131n ilerleyen zamanlarda acil servislerde daha fazla ya\u015fl\u0131 hasta ile kar\u015f\u0131la\u015fmalar\u0131 ve ya\u015fl\u0131 hasta bak\u0131m\u0131 konusundaki yetkinliklerini artt\u0131rma ihtiyac\u0131 ile sonu\u00e7lanabilir. Geriatrik n\u00fcfustaki serebrovask\u00fcler olaylara yakla\u015f\u0131mda gen\u00e7 n\u00fcfusa g\u00f6re farkl\u0131l\u0131klar bulunmakla birlikte bu yaz\u0131da geriatrik n\u00fcfustaki yakla\u015f\u0131mdan bahsedilecektir.<\/p>\n\n\n\n

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\u015eekil-1. 65 ya\u015f ve \u00fczeri grubun toplam n\u00fcfusa oran\u0131, 2013-2080 (T\u00fcrkiye)1<\/sup><\/figcaption><\/figure>\n\n\n\n

Serebrovask\u00fcler hastal\u0131klar d\u00fcnya \u00e7ap\u0131nda ikinci \u00f6nde gelen \u00f6l\u00fcm nedenidir ve yayg\u0131nl\u0131\u011f\u0131 n\u00fcfusun ya\u015flanmas\u0131 ile birlikte artmaktad\u0131r. Ya\u015f\u0131n ilerlemesiyle birlikte hem serebrovask\u00fcler hastal\u0131klara zemin haz\u0131rlayan risk fakt\u00f6rlerinin (ya\u015f, hipertansiyon, diyabet, sigara i\u00e7imi, atriyal fibrilasyon, antikoag\u00fclan kullan\u0131m\u0131) artmas\u0131 hem de beyinde meydana gelen de\u011fi\u015fiklikler geriatrik pop\u00fclasyonun serebrovask\u00fcler olaylara daha y\u00fcksek oranda yakalanmas\u0131na ve daha \u015fiddetli etkilenmesine neden olmaktad\u0131r2,3<\/sup>.<\/p>\n\n\n\n

Ba\u015fvuru \u015eekilleri ve Muayene Bulgular\u0131:<\/strong> \u00d6zel bir grup olarak de\u011ferlendirilmesi gereken ya\u015fl\u0131 hastalar\u0131n hastal\u0131k belirtileri gen\u00e7lerden farkl\u0131 olabilir ve acil servislere atipik ba\u015fvurular ile m\u00fcracaat edebilirler. Genel halsizlik\/yorgunluk yak\u0131nmas\u0131ndan koma durumuna kadar geni\u015f bir yelpazede semptom ve muayene bulgular\u0131 ile kar\u015f\u0131la\u015f\u0131labilir. Ya\u015fl\u0131 hastalar\u0131n acil serviste muayeneleri her zaman kolay olmaz. Mevcut olan bir\u00e7ok kronik hastal\u0131k ve altta yatan patoloji muayeneyi ve yeni bir hastal\u0131\u011f\u0131n te\u015fhisini g\u00fc\u00e7le\u015ftirir. Ya\u015fl\u0131 hastalarda hastal\u0131k seyrinin atipik olmas\u0131, belirtilerin ge\u00e7 \u00e7\u0131kmas\u0131 ve altta yatan hastal\u0131klar\u0131n \u00e7ok olmas\u0131 nedeniyle yard\u0131mc\u0131 te\u015fhis metodlar\u0131n\u0131n kullan\u0131lmas\u0131 s\u0131kl\u0131kla daha fazlad\u0131r. Ya\u015fl\u0131 hastalar i\u00e7in gen\u00e7lere g\u00f6re daha fazla laboratuar tetkikine, radyolojik tetkiklere ve di\u011fer yard\u0131mc\u0131 te\u015fhis y\u00f6ntemlerine ba\u015fvurulur4<\/sup>.<\/p>\n\n\n\n

Ya\u015fl\u0131 hastalardan anamnez almak olduk\u00e7a zordur. Bili\u015fsel ve fiziksel yetersizlikler y\u00fcz\u00fcnden, al\u0131nan t\u0131bbi \u00f6zge\u00e7mi\u015f bilgileri yeterli olmayabilir. Hasta ve t\u0131bbi \u00f6zge\u00e7mi\u015f bilgileri hasta yak\u0131nlar\u0131 taraf\u0131ndan do\u011frulanmal\u0131, m\u00fcmk\u00fcnse eski kay\u0131tlar\u0131 ile teyit edilmelidir. Ya\u015fl\u0131l\u0131kta olu\u015fan birtak\u0131m fizyolojik de\u011fi\u015fiklikler y\u00fcz\u00fcnden fizik muayene daha dikkatli yap\u0131lmal\u0131d\u0131r. Ya\u015fl\u0131 hastalardan benzer \u015fik\u00e2yetleri olan gen\u00e7 hastalara oranla daha fazla test istenme e\u011filimi doktorlar aras\u0131nda yayg\u0131nd\u0131r. \u00c7\u00fcnk\u00fc daha az rezervi olan ya\u015fl\u0131 hastada do\u011fru te\u015fhis koymak \u00e7ok \u00f6nemlidir. Buna g\u00f6re g\u00f6rece hafif semptomlar\u0131 olan geriatrik hastalarda mortalite ve morbiditesi y\u00fcksek olabilen tan\u0131lar ile kar\u015f\u0131la\u015f\u0131labilece\u011fi ak\u0131lda tutulmal\u0131d\u0131r4<\/sup>.<\/p>\n\n\n\n

Ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131 acil servislere de\u011fi\u015fik \u015fikayet ve yak\u0131nmalarla ba\u015fvurabilirler veya getirilebilirler. Ba\u015f a\u011fr\u0131s\u0131, bulant\u0131 ve kusma, konu\u015fma ve g\u00f6rme bozukluklar\u0131, fokal veya yayg\u0131n motor ve duyu kay\u0131plar\u0131, ba\u015f d\u00f6nmesi, denge kayb\u0131, n\u00f6bet, bilin\u00e7 de\u011fi\u015fiklikleri ve koma en s\u0131k g\u00f6r\u00fclenleridir. T\u00fcm bu semptomlar tek ba\u015f\u0131na ortaya \u00e7\u0131kabilece\u011fi gibi hastalar\u0131n birka\u00e7 semptom ve bulgunun birlikteli\u011fi ile acil servislere ba\u015fvurma olas\u0131l\u0131\u011f\u0131 daha y\u00fcksektir5<\/sup>. Ya\u015fl\u0131 hastalarda fizik muayene bili\u015fsel ve fiziksel de\u011fi\u015fiklikler nedeniyle her zaman optimal seviyede olmasa bile ayr\u0131nt\u0131l\u0131 ve dikkatli muayene ile tan\u0131ya g\u00f6t\u00fcrecek bulgulara ula\u015f\u0131labilir.<\/p>\n\n\n\n

\u0130nceleme ve Genel Yakla\u015f\u0131m:<\/strong> Geriatrik pop\u00fclasyonda serebrovask\u00fcler hastalara ilk yakla\u015f\u0131m havayolu, solunum ve dola\u015f\u0131m\u0131n de\u011ferlendirilmesi ile ba\u015flar. Bu safhada gerekli ise hava yolunu g\u00fcvenlik alt\u0131na al\u0131nacak m\u00fcdahalelerden ka\u00e7\u0131n\u0131lmamal\u0131d\u0131r. Hastalar monit\u00f6rize edilerek vital parametreleri de\u011ferlendirilmelidir. Anormal olan de\u011ferler ya\u015fl\u0131l\u0131\u011fa ba\u011flan\u0131lmamal\u0131 ve anormal de\u011ferlere sahip ya\u015fl\u0131lar mutlaka ayr\u0131nt\u0131l\u0131 olarak de\u011ferlendirilmelidir4<\/sup>. Pulse oksimetre kontrol\u00fcnde hipoksi tespit edilmesi durumunda (<%94) oksijen deste\u011fi verilmelidir, bunun d\u0131\u015f\u0131nda rutin oksijen deste\u011fi endike de\u011fildir6<\/sup>. \u0130ntraven\u00f6z (IV) yol trombolitik tedavi i\u00e7in gereklidir fakat erken sa\u011flanamamas\u0131 durumunda beyin bilgisayarl\u0131 tomografi (BT) g\u00f6r\u00fcnt\u00fclemesi IV yol sa\u011flanmas\u0131 i\u00e7in geciktirilmemelidir<\/strong>7<\/sup>. <\/strong>Hastalarda olas\u0131 disritmilerin saptanmas\u0131 i\u00e7in (\u00f6zellikle atrial fibrilasyon) kardiyak monit\u00f6rizasyon ve elektrokardiyografi (EKG) gereklidir. Fakat bu uygulamalar beyin BT g\u00f6r\u00fcnt\u00fclemesini ve trombolitik tedaviyi geciktirmeyecek \u015fekilde planlanmal\u0131d\u0131r7,8<\/sup>. Yatak ba\u015f\u0131 kan \u015fekeri \u00f6l\u00e7\u00fcm\u00fc m\u00fcmk\u00fcn olan en erken s\u00fcrede yap\u0131lmal\u0131d\u0131r. Hipoglisemi ve hipergliseminin de\u011ferlendirmenin erken safhalar\u0131nda tespit edilmesi ve tedavi edilmesi gerekir. Her ikisi de iskemik felci taklit eden semptomlar \u00fcretmekle kalmaz, ayn\u0131 zamanda devam eden n\u00f6ronal iskemiyi de \u015fiddetlendirebilir. G\u00fcncel AHA\/ASA (American Heart Association\/American Stroke Association) k\u0131lavuzlar\u0131 akut iskemik inmeden sonraki ilk 24 saat boyunca hipergliseminin normoglisemiden daha k\u00f6t\u00fc sonu\u00e7lar ile ili\u015fkili oldu\u011funu ve bu nedenle hiperglisemik hastalarda kan \u015fekeri seviyelerinin 140mg\/dl ile 180mg\/dl aral\u0131\u011f\u0131nda olacak \u015fekilde tedavi edilmesini \u00f6nermektedir9<\/sup>. Serebrovask\u00fcler hastalarda saptanan anormal v\u00fccut s\u0131cakl\u0131k de\u011ferleri h\u0131zl\u0131 bir \u015fekilde d\u00fczeltilmelidir. Hipertermi (>38\u00b0C) tespit edilmesi durumunda olas\u0131 ate\u015f odaklar\u0131 ara\u015ft\u0131r\u0131lmal\u0131d\u0131r ve antipiretik ila\u00e7lar serebrovask\u00fcler hastalar\u0131nda daha d\u00fc\u015f\u00fck s\u0131cakl\u0131klarda uygulanmal\u0131d\u0131r9<\/sup>. Serebrovask\u00fcler hastalarda ilk 24 saat i\u00e7erisindeki \u0131s\u0131 anormallikleri (<37\u00b0C ve >39\u00b0C) normotermik hastalar ile kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131nda artm\u0131\u015f mortalite oranlar\u0131 ile ili\u015fkilidir10<\/sup>. Ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131nda kan bas\u0131nc\u0131 \u00f6l\u00e7\u00fcm\u00fc ilk de\u011ferlendirmede mutlaka yap\u0131lmal\u0131d\u0131r. Hipovolemi ve\/veya hipotansiyon tespit edilmesi durumunda d\u00fczeltilmeye \u00e7al\u0131\u015f\u0131lmal\u0131d\u0131r9<\/sup>.<\/p>\n\n\n\n

Ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131n\u0131n de\u011ferlendirilmesinde rutin laboratuvar tetkikleri olmamak ile birlikte tam kan say\u0131m\u0131 (polisitemi, trombositoz veya trombositopeniyi saptamak i\u00e7in), koag\u00fclasyon incelemeleri (koag\u00fclopatiyi saptamak i\u00e7in), b\u00f6brek ve karaci\u011fer fonksiyon testleri, elektrolit d\u00fczeyleri (elektrolit bozuklu\u011funa ba\u011fl\u0131 inmeye benzer durumlar\u0131n saptanmas\u0131 i\u00e7in) ve kardiyak belirte\u00e7 d\u00fczeyleri (\u00f6zellikle troponin) istenilmelidir. Hastalardan enfeksiy\u00f6z benzeri tablosu d\u00fc\u015f\u00fcn\u00fcl\u00fcyor ise tam idrar tetkiki ve posterior-anterior akci\u011fer grafisi istemleri de yap\u0131lmal\u0131d\u0131r.<\/p>\n\n\n\n

Ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131n\u0131n de\u011ferlendirilmesinde hasta acil servise geldi\u011finde ilk istenilecek g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemi kontrasts\u0131z beyin BT<\/strong> olmal\u0131d\u0131r. Esas ama\u00e7 intrakranial kanama, t\u00fcm\u00f6r ve apse gibi durumlar\u0131 d\u0131\u015flamakt\u0131r9<\/sup>. Hastan\u0131n acil servise ba\u015fvurusundan g\u00f6r\u00fcnt\u00fclemesine kadar ge\u00e7en (kap\u0131-g\u00f6r\u00fcnt\u00fcleme s\u00fcresi) s\u00fcre 20 dakikan\u0131n alt\u0131nda<\/strong> olmal\u0131d\u0131r11<\/sup>. Her ne kadar dif\u00fczyon a\u011f\u0131rl\u0131kl\u0131 manyetik rezonans (MR) g\u00f6r\u00fcnt\u00fclemesi akut infarktlar\u0131n saptanmas\u0131nda beyin BT\u2019den \u00fcst\u00fcn olsa da, BT\u2019nin yayg\u0131n ve kolay ula\u015f\u0131labilirli\u011fi ayn\u0131 zamanda MR\u2019\u0131n \u00e7ekimi ile ilgili zorluklar (\u00f6zellikle ya\u015fl\u0131 pop\u00fclasyonda daha s\u0131k kar\u015f\u0131la\u015ft\u0131\u011f\u0131m\u0131z hasta uyumundaki zorluk, kalp pili ve metal protez varl\u0131\u011f\u0131) akut iskemik inmede BT\u2019yi en uygun g\u00f6r\u00fcnt\u00fcleme y\u00f6ntemi y\u00f6n\u00fcnde destekler9<\/sup> (Resim-1). Endovask\u00fcler tedavilerin (intraarteriel tromboliz\/mekanik trombektomi) geli\u015fip yayg\u0131nla\u015fmas\u0131 ile birlikte vask\u00fcler g\u00f6r\u00fcnt\u00fclemenin \u00f6nemi artm\u0131\u015ft\u0131r. Endovask\u00fcler tedaviye aday hastalar\u0131n vask\u00fcler g\u00f6r\u00fcnt\u00fclemesinin ilk kontrasts\u0131z beyin BT ile e\u015f zamanl\u0131 olarak beyin ve boyun BT anjiyografi (intrakranial ve ekstrakranial) olarak \u00e7ekilmesi \u00f6nerilir.<\/p>\n\n\n\n

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Resim-1. \u0130skemik inme hastas\u0131n\u0131n kontrasts\u0131z beyin BT(a) g\u00f6r\u00fcnt\u00fclesinde sa\u011f parietooksipital lobda hipodansite (akut\/subakut infarkt), yine ayn\u0131 hastan\u0131n dif\u00fczyon MR(b) ve FLAIR(c) g\u00f6r\u00fcnt\u00fclerinde ayn\u0131 anatomik b\u00f6lgede intensite art\u0131\u015flar\u0131 g\u00f6r\u00fclmektedir. (Tekirda\u011f Nam\u0131k Kemal \u00dcniversitesi Hastanesi Ba\u015fhekimli\u011fi\u2019nin E-45976400-622.03-34121 say\u0131l\u0131 izniyle kullan\u0131lm\u0131\u015ft\u0131r)<\/figcaption><\/figure>\n\n\n\n

Y\u00f6netim:<\/strong> Ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131n\u0131n tedavisinin birincil amac\u0131 ilk stabilizasyonu sa\u011fland\u0131ktan sonra k\u00f6t\u00fcye gidi\u015fin \u00f6nlenmesi ve perf\u00fczyonun tekrardan sa\u011flanmas\u0131na y\u00f6nelik tedavilerin planlanmas\u0131d\u0131r. \u00d6ncelikle havayolunu, solunumu ve dola\u015f\u0131m\u0131 d\u00fczenleyici \u00f6nlemler al\u0131nmal\u0131d\u0131r. Hastalarda dehidratasyon<\/strong> bulgular\u0131 mevcut ise IV kristaloidlerle d\u00fczeltilmeye \u00e7al\u0131\u015f\u0131lmal\u0131d\u0131r. Ya\u015fl\u0131 iskemik inme hastalar\u0131n\u0131n acil servise kabul\u00fcnden sonra sedyedeki kafa pozisyonun durumu belirsizdir. Supin pozisyon (0\u00b0) ve ba\u015f y\u00fckseltilmi\u015f (>30\u00b0) durumlar\u0131n kar\u015f\u0131la\u015ft\u0131r\u0131ld\u0131\u011f\u0131 durumlarda her iki durum aras\u0131nda fayda ve komplikasyon a\u00e7\u0131s\u0131ndan fark g\u00f6zlemlenmemi\u015ftir12<\/sup>. Hemorajisi olan hastalar yatak ba\u015f\u0131 30\u00b0 kald\u0131r\u0131larak takip edilmelidir. Ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131n kan bas\u0131nc\u0131 kontrol\u00fc b\u00fcy\u00fck \u00f6nem arz eder. Bu hasta gruplar\u0131nda ya\u015fa ba\u011fl\u0131 aterosklerotik s\u00fcre\u00e7, ek hastal\u0131klar\u0131n mevcudiyeti ve \u00e7oklu ila\u00e7 kullan\u0131mlar\u0131 hedef tansiyon de\u011feri belirlenmesini pek m\u00fcmk\u00fcn k\u0131lmasa da genel kan\u0131 ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131nda kan bas\u0131nc\u0131<\/strong> de\u011ferlerini  sistolik <185 mmHg ve diyastolik <100 mmHg\u2019n\u0131n alt\u0131nda olmas\u0131 y\u00f6n\u00fcndedir9<\/sup>. Antihipertansif ajan olarak labetalol, nicardipin ve clevidipin kullan\u0131la bilir9<\/sup>. Ya\u015fl\u0131 serebrovask\u00fcler hastalarda, ya\u015fa ba\u011fl\u0131 ek hastal\u0131k ya da antikoag\u00fclan kullan\u0131m\u0131na ba\u011fl\u0131 koag\u00fclasyon bozukluklar\u0131 sebebiyle kafa i\u00e7i kanamalar\u0131 g\u00f6r\u00fclebilir. Acil tedavide g\u00fcncel yakla\u015f\u0131m h\u0131zl\u0131 ve etkin olarak anti-koag\u00fclasyonun tersine \u00e7evrilmesidir. Bunun i\u00e7in K vitamini, taze donmu\u015f plazma (TDP), rekombinant fakt\u00f6r VIIa (rFVIIa) ve protrombin kompleks konsantreleri (PCC) kullan\u0131labilir13<\/sup>.<\/p>\n\n\n\n

Ya\u015fl\u0131 serebrovask\u00fcler hastalarda IV fibrinoliz tedavisi endike hastalarda m\u00fcmk\u00fcn oldu\u011funca erken s\u00fcrede verilmelidir.\u00a0 IV fibrinoliz uygulama karar\u0131 do\u011fru ve h\u0131zl\u0131 bir \u015fekilde verilmelidir. Tedaviye ba\u015flamadan \u00f6nce hastan\u0131n en son normal g\u00f6r\u00fcld\u00fc\u011f\u00fc zaman do\u011fru bir \u015fekilde teyit edilmeli ve yararlar ve potansiyel riskler de\u011ferlendirilmelidir. AHA\/ASA \u00f6nerileri do\u011frultusunda inme semptomlar\u0131n\u0131n ba\u015flamas\u0131ndan sonraki ilk \u00fc\u00e7 saat (0-3 saat)<\/strong> i\u00e7erisinde ba\u015fvuran ve IV alteplaz tedavinin kesin d\u0131\u015flama kriterlerini (Tablo-1\u2019de g\u00f6sterilmi\u015ftir) sa\u011flamayan 18 ya\u015f ve \u00fczerindeki t\u00fcm hastalar IV fibrinoliz i\u00e7in adayd\u0131r ve tedavi m\u00fcmk\u00fcn olan en k\u0131sa s\u00fcrede ba\u015flan\u0131lmal\u0131d\u0131r9<\/sup>. Se\u00e7ilmi\u015f vakalarda 3-4,5 saatlik<\/strong> s\u00fcre\u00e7te de IV fibrinoliz tedavisi uygulanabilir9<\/sup>. G\u00f6r\u00fcld\u00fc\u011f\u00fc \u00fczere ya\u015f IV fibrinoliz tedavisi i\u00e7in ya\u015f bir kontrendike de\u011fildir ve endike olan hasta gruplar\u0131na uygulanmal\u0131d\u0131r.<\/p>\n\n\n\n

Tablo-1. IV Alteplaz Tedavinin Kesin D\u0131\u015flama Kriterleri<\/a><\/strong>7,9<\/sup><\/td><\/tr>
Fonksiyonel bozuklu\u011fa neden olmayan inme (NIHSS 0-5)<\/td><\/tr>
Beyin BT\u2019de belirgin ve geni\u015f hipodansite<\/td><\/tr>
Beyin BT\u2019de intrakranial kanama varl\u0131\u011f\u0131<\/td><\/tr>
3 ay i\u00e7erisinde ge\u00e7irilmi\u015f iskemik inme \u00f6yk\u00fcs\u00fc<\/td><\/tr>
3 ay i\u00e7erisinde ciddi kafa travmas\u0131 \u00f6yk\u00fcs\u00fc<\/td><\/tr>
Hastane i\u00e7i d\u00f6nemde ortaya \u00e7\u0131kan post travmatik beyin enfarkt\u00fcs\u00fc<\/td><\/tr>
3 ay i\u00e7erisinde ge\u00e7irilmi\u015f intrakranial\/spinal cerrahi \u00f6yk\u00fcs\u00fc<\/td><\/tr>
\u0130mtrakranial kanama \u00f6yk\u00fcs\u00fc<\/td><\/tr>
Subaraknoid kanamay\u0131 d\u00fc\u015f\u00fcnd\u00fcren semptom ve bulgular\u0131n olmas\u0131<\/td><\/tr>
21 g\u00fcn i\u00e7erisinde G\u0130 malignite veya G\u0130 kanama \u00f6yk\u00fcs\u00fc<\/td><\/tr>
Trombosit <100.000\/mm3 <\/sup>(Hastada trombositopeni \u00f6yk\u00fcs\u00fc yok ise IV alteplaz tedavi trombosit sonucu \u00e7\u0131kmadan ba\u015flan\u0131labilir. Trombosit say\u0131s\u0131 <100.000\/mm3<\/sup> saptan\u0131rsa IV alteplaz tedavisi durdurulur)<\/td><\/tr>
INR>1.7 veya aPTT>40 sn veya PT>15 sn (Hasta oral antikoag\u00fclan veya heparin alm\u0131yor ise IV alteplaz tedavi bu laboratuvar testleri sonu\u00e7lanmadan ba\u015flan\u0131labilir. Ancak laboratuvar sonu\u00e7lar\u0131 normal s\u0131n\u0131rlar\u0131n \u00fcst\u00fcnde \u00e7\u0131karsa tedavi durdurulmal\u0131d\u0131r)<\/td><\/tr>
Son 24 saat i\u00e7erisinde d\u00fc\u015f\u00fck molek\u00fcl a\u011f\u0131rl\u0131kl\u0131 heparin kullan\u0131m\u0131<\/td><\/tr>
Direkt trombin veya direkt fakt\u00f6r Xa inhibit\u00f6r\u00fc alan hastalar (Hastan\u0131n bu ila\u00e7lardan birini son kullan\u0131m s\u00fcresi >48 saat ise ve b\u00f6brek fonksiyonlar\u0131 normal ise p\u0131ht\u0131la\u015fma sonu\u00e7lar\u0131 \u00e7\u0131kmadan IV alteplaz verilebilir)<\/td><\/tr>
Abciximab (glikoprotein IIb\/IIIa resept\u00f6r inhibit\u00f6r\u00fc) kullan\u0131m\u0131<\/td><\/tr>
Akut iskemik inme ile e\u015f zamanl\u0131 enfektik endokardit birlikteli\u011fi<\/td><\/tr>
Bilinen veya \u015f\u00fcphelenilen aort diseksiyonu varl\u0131\u011f\u0131<\/td><\/tr>
\u0130ntraaksiyel intrakranial kanser<\/td><\/tr>
Kan \u015fekeri <50 mg\/dl \u00f6l\u00e7\u00fclm\u00fc<\/td><\/tr><\/tbody><\/table><\/div>
G\u0130:Gastrointestinal, INR: International Normalized Ratio, aPTT:Activated partial thromboplastin time, PT: Prothrombin time<\/figcaption><\/figure>\n\n\n\n

Ya\u015fl\u0131 serebrovask\u00fcler hastalardaki bir di\u011fer sorun malignite mevcudiyetidir. Malignitesi olan hastalarda IV alteplaz\u0131n g\u00fcvenilirli\u011fi tam olarak belirlenememi\u015f olsa da ya\u015fam beklentisi 6 ay ve \u00fczeri olan, p\u0131ht\u0131la\u015fma bozuklu\u011fu olmayan, yak\u0131n zamanda ge\u00e7irilmi\u015f cerrahisi olmayan ve kanamas\u0131 olmayan hastalarda IV alteplaz tedavisi d\u00fc\u015f\u00fcn\u00fclebilir9<\/sup>.<\/p>\n\n\n\n

Giri\u015fimsel radyolojik imkanlar\u0131n geli\u015fmesi ile birlikte iskemik inme hastalar\u0131nda \u00f6zellikle intraarteriyel tromboliz ve mekanik trombektomi olmak \u00fczere endovask\u00fcler tedaviler gittik\u00e7e artmaktad\u0131r. Uzam\u0131\u015f zaman aral\u0131\u011f\u0131nda (>6 saat) uygulanabilmeleri ve trombolitik ila\u00e7lar\u0131n d\u00fc\u015f\u00fck dozlarda kullan\u0131lmas\u0131 gibi avantajlar\u0131 olan bu y\u00f6ntemler endike olan hastalarda uygulanmal\u0131d\u0131r. Bu hastalar m\u00fcmk\u00fcnse serebrovask\u00fcler hastal\u0131klar konusunda tecr\u00fcbeli \u00fcnitelerde veya uzmanla\u015fm\u0131\u015f yo\u011fun bak\u0131m birimlerinde takip edilmelidir.<\/p>\n\n\n\n

Her \u015feyden \u00f6nce \u015fu unutulmamal\u0131d\u0131r ki ya\u015fl\u0131 serebrovask\u00fcler hastalar\u0131n acile geli\u015f \u015fekilleri genellikle karma\u015f\u0131kt\u0131r. Birden fazla kronik hastal\u0131k ve \u00e7oklu ila\u00e7 kullan\u0131m\u0131n\u0131n etkileri g\u00f6z \u00f6n\u00fcne al\u0131nmal\u0131 ve azalm\u0131\u015f fonksiyonel durumlar\u0131 olabilece\u011fi ak\u0131lda tutulmal\u0131d\u0131r. Yeni \u015fikayet ve bulgular\u0131n do\u011fru de\u011ferlendirilebilmesi i\u00e7in \u00f6nceki fonksiyonel durumlar\u0131 iyi bilinmeli ve sorgulanmal\u0131d\u0131r4<\/sup>.<\/p>\n\n\n\n

KAYNAKLAR<\/strong><\/p>\n\n\n\n

1.        Tar Y, Dayal A, Dayal A. \u0130statistiklerle Ya\u015fl\u0131lar, 2022. T\u00fcrkiye \u0130statistik Kurumu. Published 2023. https:\/\/data.tuik.gov.tr\/Bulten\/Index?p=Istatistiklerle-Yaslilar-2022-49667<\/p>\n\n\n\n

2.        Ergin Beton \u00d6, \u015eahin MH, Do\u011fan H, Bilen \u015e, Bekta\u015f H. Prognosis and Risk Factors for Geriatric Stroke Patients in Each Decade. Turk Geriatr Derg<\/em>. 2023;26(3):285-293. doi:10.29400\/tjgeri.2023.355<\/p>\n\n\n\n

3.        Lal BK, Cires-Drouet RS. Cerebrovascular Disease in the Elderly. In: Chaer R, ed. Vascular Disease in Older Adults<\/em>. Springer International Publishing; 2017:113-125. doi:10.1007\/978-3-319-29285-4_6<\/p>\n\n\n\n

4.        Kunt MM. Ya\u015fl\u0131l\u0131k D\u00f6neminde Acil Sorunlar. In: Birinci Basamak I\u00e7in Temel Geriatri<\/em>. Ankara Tabip Odas\u0131; 2012:66-73.<\/p>\n\n\n\n

5.        Jauch EC, Almallouhi E, Holmstedt CA. Acute management of stroke. Br J Cardiol<\/em>. 2001;8(11):654-657.<\/p>\n\n\n\n

6.        Roffe C, Nevatte T, Sim J, et al. Effect of Routine Low-Dose Oxygen Supplementation on Death and Disability in Adults With Acute Stroke. JAMA<\/em>. 2017;318(12):1125. doi:10.1001\/jama.2017.11463<\/p>\n\n\n\n

7.        Go S. Stroke Syndromes. In: J.E. Tintinalli, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM  et al., ed. Tintinalli\u2019s Emergency Medicine A Comprehensive Study Guide<\/em>. Ninth Edit. McGraw-Hill Education; 2020:1119\u20131136.<\/p>\n\n\n\n

8.        Wu F, Cao W, Ling Y, Yang L, Cheng X, Dong Q. The predictive role of electrocardiographic abnormalities in ischemic stroke patients with intravenous thrombolysis. IJC Hear Vessel<\/em>. 2014;4(1):81-83. doi:10.1016\/j.ijchv.2014.06.010<\/p>\n\n\n\n

9.        Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke a guideline for healthcare professionals from the American Heart Association\/American Stroke A. Stroke<\/em>. 2019;50(12):E344-E418. doi:10.1161\/STR.0000000000000211<\/p>\n\n\n\n

10.      Saxena M, Young P, Pilcher D, et al. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection. Intensive Care Med<\/em>. 2015;41(5):823-832. doi:10.1007\/s00134-015-3676-6<\/p>\n\n\n\n

11.      Lees KR, Emberson J, Blackwell L, et al. Effects of Alteplase for Acute Stroke on the Distribution of Functional Outcomes: A Pooled Analysis of 9 Trials. Stroke<\/em>. 2016;47(9):2373-2379. doi:10.1161\/STROKEAHA.116.013644<\/p>\n\n\n\n

12.      Anderson CS, Arima H, Lavados P, et al. Cluster-Randomized, Crossover Trial of Head Positioning in Acute Stroke. N Engl J Med<\/em>. 2017;376(25):2437-2447. doi:10.1056\/nejmoa1615715<\/p>\n\n\n\n

13.      Hartman SK, Teruya J. Practice Guidelines for Reversal of New and Old Anticoagulants. Disease-a-Month<\/em>. 2012;58(8):448-461. doi:10.1016\/j.disamonth.2012.04.003<\/p>\n","protected":false},"excerpt":{"rendered":"

Giri\u015f \/ Epidemiyoloji: Yirminci y\u00fczy\u0131l\u0131n ortalar\u0131ndan itibaren ya\u015fl\u0131 n\u00fcfus artmaya ba\u015flam\u0131\u015f ve bu art\u0131\u015f 21. y\u00fczy\u0131lda daha da fazlala\u015fm\u0131\u015ft\u0131r. D\u00fcnya\u2019da ve T\u00fcrkiye\u2019de…<\/p>\n","protected":false},"author":1185,"featured_media":565,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[1,10014],"tags":[10042,10018,10043],"class_list":["post-562","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-genel","category-akademik-blog-yazisi","tag-acil","tag-geriatri","tag-inme"],"acf":[],"_links":{"self":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/562","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/users\/1185"}],"replies":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/comments?post=562"}],"version-history":[{"count":0,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/posts\/562\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media\/565"}],"wp:attachment":[{"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/media?parent=562"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/categories?post=562"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tatd.org.tr\/geriatri\/wp-json\/wp\/v2\/tags?post=562"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}