Krvácení do mozku

23.4.2012 , Danica Deretić

krvaceni-do-mozku.jpg - kopie
krvaceni-do-mozku.jpg - kopie
Krvácení do mozku patří do skupiny nitrolebních krvácení, které může mít vážné až fatální následky. Krvácení do mozku může vznikat jako následek poranění, po mozkové mrtvici, při prasknutí výdutě v mozkové tepně a dalších onemocnění. Následky krvácení jsou závislé na jeho příčině, rozsahu i umístění. Pacient se může zcela uzdravit, anebo může krvácení skončit i smrti pacienta. Léčba krvácení do mozku zaznamenala obrovského zlepšení s rozvojem moderních technik diagnostiky, díky nimž je možné podniknout dříve léčebná opatření.

Krvácení do mozku

Krvácení do mozku patří do velké skupiny nitrolebních krvácení spolu s krváceními mezi mozkové pleny. Masivní krvácení do mozku vzniká náhle a proto má nejčastěji prudký vývoj. Následky krvácení do mozku bývají velmi vážné a vést až ke smrti pacienta. Krvácení mozku vzniká nejčastěji při prasknutí cévy v důsledku vysokého krevního tlaku, nebo při úrazech. Mozek je chráněn 3 mozkovými obaly, tvrdou plenou, pavučnicí a měkkou plenou a podle prostoru, do kterého se krev po poranění cévy dostává rozlišujeme několik typů krvácení do mozku, a to epidurální krvácení, subdurální krvácení a krvácení subarachnoidální.

Příčiny vzniku krvácení do mozku

Příčiny vzniku krvácení do mozku jsou různé. Nejčastější příčinou vzniku rozsáhlého krvácení do mozku je prasknutí cévy při vysokém krevním tlaku. Méně častou příčinou krvácení do mozku bývají výdutě v tepnách, vzniklých vakovitým rozšířením jejich oslabené stěny např. při kornatění tepen. Neméně častou příčinou jsou i traumata hlavy. Kromě rozsáhlých krvácení existuje ještě krvácení vlásečnicového původu, kde příčin je celá řada. Příkladem mohou být krevní onemocnění jako jsou leukémie, infekce, otravy, úrazy hlavy, úpal a další. Stav je většinou provázen těžkou poruchou mozkových funkcí a hlubokým bezvědomím.

Typy krvácení do mozku

Krvácení do mozku vzniká z různých příčin a podle nich se setkáváme s jednotlivými typy krvácení do mozku. Při traumatech hlavy se setkáváme s epidurálním, či subdurálním krvácením, při prasknutí cévní výdutě vzniká nejčastěji subarachnoidální krvácení a vysoký krevní tlak vede k prasknutí malých cév a ke vzniku cévní mozkové příhody, kdy se typicky objevuje krvácení do mozkové tkáně.

Epidurální krvácení

Epidurální krvácení znamená výron krve mezi mezi lebkou a tvrdou plenou a vzniká nejčastěji v důsledku úrazu hlavy. Nejčastějším mechanismem bývá úder do spánkové oblasti hlavy. Až u 75% pacientů se vyskytuje rovněž i prasklina v lebeční kosti. Epidurální krvácení se rozvíjí většinou několik hodin po úrazu a dominujícím příznakem je postupné zhoršování stavu vědomí. V důsledku výronu krve, který zvyšuje nitrolební tlak a utlačuje různé části mozku se u epidurálního krvácení mohou vyskytnout i poruchy řeči, částečná, či úplná porucha hybnosti, nebo epileptické záchvaty. Přítomny bývají i poruchy pohybu očí a jednostranná rozšířená zornice. Diagnóza se stanovuje pomocí CT vyšetření, které je nezbytné provést co nejdříve, jelikož se jedná o život ohrožující stav, který se musí řešit operativně. Krev se musí co nejdříve vypustit a tím dojde ke snížení nitrolebního tlaku, který by jinak vedl k útlaku mozkového kmene a k mozkové smrti.

Subdurální krvácení

Subdurální krvácení představuje výron krve mezi tvrdou plenu a pavučnicí a zdrojem bývají prasklé žíly při úrazu hlavy. Subrudální krvácení může probíhat akutně, subakutně, či chronicky.

Akutní subdurální krvácení se projevuje během 1 až 2 dnů od úrazu a bývá spojen s pohmožděním mozku. Nejzávažnější a nejdůležitější je takové krvácení, které vede k vzestupu nitrolebního tlaku a útlaku mozku. To je příčinou zhoršujícího se stavu vědomí, rozvoji částečné poruchy hybnosti a různé šířky zornic. Diagnostika subdurálního krvácení je náročná zejména u pacientů v bezvědomí, ale i v tomto případě je nezbytné co nejdříve provést CT, které subdurální krvácení odhalí. Léčba spočívá v chirurgickém zákroku vedoucímu k evakuaci nahromaděné krve.

Subakutní subdurální krvácení se projevuje do 3 týdnů od úrazu a setkáváme se s ním u lidí ve vyšším věku, nebo u méně závažných poranění. I zde je dominujícím příznakem zhoršování stavu vědomí, spolu s bolestmi hlavy a závratěmi.

Chronické subdurální krvácení se projeví za týdny až měsíce od úrazu. Vyskytuje se u starších pacientů, nebo u alkoholiků, u kterých dochází k atrofii mozku, tedy k jeho zmenšení. Tak se vytváří prostor, ve kterém se při nevelkém krvácení může krev hromadit, aniž by utlačovala mozkovou tkáň. Vytváří se opouzdřený krevní výron, který se postupně zvětšuje v důsledku přesunu tekutiny přes pouzdro a to vede ke zvyšování nitrolebního tlaku. Pacient tak bývá utlumený, zmatený, může mít bolesti hlavy, závratě a poruchy afektivity. Diagnóza se opět potvrdí pomocí CT a léčba je i zde operační.

Subarachnoidální krvácení

Subarachnoidální krvácení znamená vznik krevního výronu mezi měkkou plenou a pavučnicí, což znamená prosto, kde se nachází mozkomíšní mok. Příčinou je prasknutí vakovité výdutě z tepny nejčastěji na bazi mozku. Výdutě se tvoří na základě vrozeného oslabení cévní stěny, nebo získaného oslabení cévní stěny vlivem vysokého krevního tlaku. Další možnou příčinou jsou tzv. arterio-venózní malformace, krvácivé choroby, nebo vaskulopatie, tedy onemocnění cév, nebo po úrazu. Subarachnoidální krvácení se projevuje náhle vzniklou silnou bolestí hlavy, zvracením a poruchou vědomí. Později, po několika hodinách, se mohou objevit i teploty a meningeální jevy, což jsou neurologické příznaky z dráždění mozkomíšních plen. Stanovení diagnózy subarachnoidálního krvácení vychází z CT vyšetření a z vyšetření mozkomíšního moku, ve kterém objevíme krev. Dalším vyšetření, které se provádí při podezření na subarachnoidální krvácení je angiografie, kdy se pomocí katétru a kontrastní látky zobrazí průběh daných tepen. Léčba subarachnoidálního krvácení spočívá v absolutním klidu na lůžku, tlumení zvracení a bolesti hlavy pomocí léků a podle aktuálního stavu je pacient indikován k operativnímu řešení.

Krvácení do mozku při cévní mozkové příhodě

Krvácení do mozku při tzv. hemoragické cévní mozkové příhodě vzniká vlivem protržení malých tepen nejčastěji vlivem vysokého krevního tlaku. Projevy mozkových krvácení závisí na rozsahu a charakteru krvácení. Pokud je krvácení do mozku většího rozsahu, dochází ve většině případů k destrukci mozkové tkáně, což se projeví bolestmi hlavy, zvracením, poruchou vědomí a pacient je ohrožen na životě. Při menším krvácení je mozková tkáň utlačována a projevuje se to příznaky podle toho v jaké oblasti mozku ke krvácení dochází. Diagnostika krvácení do mozku při cévní mozkové příhodě spočívá v provedení CT vyšetření a některých laboratorních testů se zaměřením na krevní obraz, hematokrit, hladinu cukru v krvi a mineralogram. Nezbytnou součástí diagnostiky je i provedení EKG, tedy elektrokardiografie.Léčba akutního stádia spočívá v korekci vysokého krevního tlaku, mozkového edému. V těžších případech se přustupuje k chirurgické léčbě.

  Rizikové faktory krvácení do mozku

Nejzávažnějším rizikovým faktorem pro vznik krvácení do mozku je vysoký krevní tlak, neboli hypertenze. Při vysokém krevním tlaku dochází k namáhání tepen, jejichž stěna se díky tomu ztenčuje a je tak náchylnější k praskání. Pokud je přítomné vrozené oslabení cévní stěny, je pacient ohrožen možností prasknutí cévy dříve než ti, kteří tuto predispozici nemají. Riziko vzniku krvácení do mozku zvyšuje kouření, alkohol a některé léky. V neposlední řadě to jsou úrazy, či automobilové havárie.

Komplikace krvácení do mozku

Krvácení do mozku vede v důsledku útlaku mozkové tkáně ke tvorbě řady klinických příznaků, ale i komplikací. Jsou to především neurologické projevy, jako je úplná, či částeční ztráta motorické hybnosti, epileptické záchvaty, zmatenost až různě hluboké poruchy vědomí, zvracení, nebo bolesti hlavy. U krvácení do mozku, které vzniká následkem prasknutí cévní výdutě hrozí riziko opětovného protržení a nového krvácení.

 

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