Teškoćegutanja (disfagija) i moždani udar. Zdravka Poljaković, JIL Klinike za neurologiju KBC Zagreb
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1 Teškoćegutanja (disfagija) i moždani udar Zdravka Poljaković, JIL Klinike za neurologiju KBC Zagreb
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3 Planiranje, senzorno procesuiranje procesuiranje gutanja, regulacija motorike, izvršna motorika
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5 Cerebralni pedunkuli moždano deblo Descendentni putevi (korteks deblo) Generator potrebnih pokreta /regulacija gutanja Sensory impulses reach the brainstem primarily through the 7th, 9th, and 10 cranial nerves, while the efferent (motor) function is mediated through the 9th, 10th, 12th cranial nerves.cricopharyngeal sphincter opening is reflexive, relaxation occurring at the time when the bolus reaches the posterior pharyngal wall prior to reaching this sphincter. Cranial Nerves CN V -- Trigeminal contains both sensory and motor fibers that innervate the face important in chewing CN VII -- Facial contains both sensory and motor fibers important for sensation of oropharynx & taste to anterior 2/3 of tongue CN IX -- Glossopharyngeal contains both sensory and motor fibers important for taste to posterior tongue, sensory and motor functions of the pharynx CN X -- Vagus contains both sensory and motor fibers important for taste to oropharynx, and sensation and motor function to larynx and laryngopharynx. important for airway protection CN XII -- Hypoglossal contains motor fibers that primarily innervate the tongue
6 Oštećenje motoričkog korteksa / centara za gutanje ili centara u moždanom deblu = smetnje gutanja (ACM, VB sliv) Najčešći uzrok disfagije je moždani udar Komplikacije mogu biti fatalne (malnutricija, aspiracija pneumonija) GB dodatni troškovi oko 400 mil funti/god
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8 Često dokumentirana Vrlo različita učestalost u različitim studijama Rano otkrivanje i rehabilitacija disfagije kod bolesnika s MU smanjuje broj komplikacija i dužinu boravka bolesnika u bolnici Ciljane studije o učestalosti disfagije posljedicama disfagije
9 Mali broj studija Mali broj bolesnika u studiji (manje od 100) Različiti ulazni kriteriji različita kategorija bolesnika Početak i vrijeme praćenja nekomparabilni Težina MU Komorbiditet Metode identifikacije NODa
10 Screening metoda uz krevet bolesnika liječnik/ms/logoped Uzimanje tekućine dispraksija gutanje aspiracija mišići koji sudjeluju u gutanju aspiracija nedostatak zraka kašalj glas... Faringealni refleks nema značaj Subjektivna, ovisi o iskustvu znanju kliničara
11 INCIDENCIJA 23 51% 14 81% Dizajn studije, način identifikacije odnosno postavljanja dijagnoze (klinički screening, dijagnostičkim metodama, kombinacija)
12 STUDIJE... 22% unutar 2 dana 15% unutar mjesec dana VFS 64% unutar deset dana / 22% aspiracijske pneumonije Nakon 6 mj čak 80% bolesnika je imalo različite smetnje gutanja, ipak ¾ se vratilo na prehranu prije MU
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15 Sensitivity and specificity for aspiration assessed with bedside swallow tests compared with videofluoroscopy Researchers Patients studied Sensitivity ( %) Specificity (%) Smithard et al DePippo et al Splaingard et al Smith et al Daniels et al McCullough et al Nishiwaki
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18 DA LI JE DISFAGIJA KLINIČKI ZNAČAJAN POREMEĆAJ? Pregledna studija na bolesnika u SAD trostruki rizik za fatalni ishod ako bolesnik s MU razvije pneumoniju Mortalitet za bolesnike koji imaju MU i disfagiju: 27 37% Statistički značajno veća smrtnost unutar prvih 6 mj kod onih koji imaju disfagiju
19 PEG Nije zamjena za rehabilitaciju 126 bolesnika s PEGom u praćenju od 31 mj 57% fatalni ishod, 29% nakon 3 mj bez PEGa,... Moguć oporavak i nakon više godina od MU
20 Anatomija orofarinksa: Anatomija orofarinksa: 1.Ramus mandibule 2.Tvrdo nepce 3.Meko nepce 4.Farinks 5.Epiglotis 6.Laringealni vestibulum 7.Glasnice 8.Trahea 9.Gornji ezofagealni sfinkter 10.Početak ezofagusa
21 Cerebrum Cerebelum Moždano deblo Hemisferični MU prekid voljne kontrole žvakanja i prenosa zalogaja u oralnoj fazi. Precentralni girus kontralateralno oštećenje lica, jezika, motoričke kontrole, peristaltike farinksa Kognitivne funkcije koncentracija, selektivna pažnja Moždano deblo najteža oštećenja (osjet jezika, usta, obrada, vremenski slijed potrebnih pokreta, laringealna elevacija, zatvaranje glotisa, krikofaringealna relaksacija) Dob bolesnika nije zanemariva!
22 Oštećenja uglavnom unilateralna 40% bolesnika s disfagijom unilateralno oštećenje Korteks desne hemisfere = oštećenje farinksa
23 Trankranijalna magnetska stimulacija (TMS) ispitivanje uloge motoričkog korteksa kod zdravih osoba i kod MU (bezopasna (?), sigurna, neinvazivna metoda stimulacije žarišnih točaka u korteksu mapiranje) Snaga učinka stimulacije (korteks izvršni mišić) mjeri se elektromiografski
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25 Inicijalne studije kod zdravih dobrovoljaca medijalni mišići žvakači imaju bilateralnu prezentaciju u motoričkom korteksu Postoji li dominantna hemisfera za gutanje? Ako je ona pogođena teže su smetnje gutanja...? Kod 20 bolesnika s MU učinjena je TMS i EMG na faringealnom mišiću. 8 ih je imalo disfagiju Stimulacija bolesne hemisfere rezultirala je jednako niskim EMG odgovorima i kod bolesnika s disfagijom i kod onih bez nje. Stimulacija zdrave hemisfere rezultirala je isto tako nižim odgovorom u obje grupe, ali daleko lošijim u grupi s disfagijom
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27 Desni orbito F korteks Lijevi mezijalni premotorni korteks i cingulum Desni i lijevi kaudolateralni senzomotorni korteks Desna inzula Desna amigdala Lijevi medijalni dio cerebelarne hemisfere Dorzalni dio debla
28 Figure 4 Graphical representation of the changes in cortical maps after a left hemisphere stroke over a period of three months. Reprinted from Hamdy S, Aziz Q, Rothwell JC, et al. Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology 1998;115: with permission from American Gastroenterological Association.
29 OPORAVAK prati kortikalna reorganizacija ali zdrave polovice korteksa (TMS/EMG) Bolesnici koji su se oporavili pokazali su rast odgovora u kortikalnim mapama kontralateralne hemisfere, oni koji se nisu oporavili nisu imali takav nalaz
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32 Postulated mechanisms for recovery after stroke have included restoration of function within viable cortex in the damaged hemisphere and/or functional reorganization within cortex of the undamaged hemisphere Most current neuro rehabilitative treatments available for stroke lack objective scientific evidence to support their eficacy. Furthermore, while neuroprotective agents in the acute phase of the stroke have shown promise, the majority of stroke victims are unlikely to benefit from such interventions due to the limited `time window' for therapeutic effect. There is, therefore, a clear need to develop novel approaches to neuro rehabilitation, based on objective scientific methods, and centred around an understanding of how human neuroplasticity can be manipulated.
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34 Zdrava hemisfera izrazito važna uloga u oporavku gutanja Ovisnost o plastičnosti zdravog dijela mozga Terapija aktivirati reorganizaciju korteksa zdrave strane Senzorni eferentni put u ždrijelu tijekom gutanja = glavni senzorni input u centre za gutanje u području moždanog debla ali i korteksa Stimulacija n X i nv prolongirana električna stimulacija Mogućnost bržeg oporavka?
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