#1
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îñëîæíåííàÿ ìèãðåíü(G43.3)
Óâàæàåìûå êîëëåãè, ìíå íåîáõîäèìà ïîìîùü ëþäåé çíàêîìûõ ñ òàêîé ïðîáëåìîé êàê îñëîæíåííàÿ ìèãðåíü.
 äàííûé ìîìåíò ó ìåíÿ â ïàëàòå ëåæèò ïàöèåíòêà ïî ïîâîäó êîòîðîé íå ìîãó îïðåäëèòüñÿ ñ òî÷íûì äèàãíîçîì. Æåíùèíà 37ëåò, ñ 13 ëåò ñòðàäàåò îäíîòèïíûìè ïèñòóïàìè îäíîñòîðîííåé ãîëîâíîé áîëè, ïóëüñèðóþùåãî õàðàêòåðà ñîïðîâîæäàþùèåñÿ ôîòî, è ôîíîôîáèåé, òîøíîòîé è èíîãäà ðâîòîé, ïðîäîëæèòåëüíîñòüþ îêîëî 4-5 ÷àñîâ(íå áóäó çàíèìàòü ìíîãî âðåìåíè, âîîáùåì ïîëíîñòüþ ïîäõîäèò ïî êðèòåðèé äèàãíîçà ìèãðåíü), âî âðåìÿ ïðèñòóïà âñåãäà îòìå÷àëà ïðåõîäÿùåå íàðóøåíèå ðå÷è(íå ìîãëà ïðîèçíîñèòü íåêîòîðûå ñëîâà,èëè îáùàëàñü òîëüêî âåðáàëüíûìè ïåðñåâèðàöèÿìè), ïðîäîëæèòåëüíîñòü ðå÷åâûõ ðàññòðîéñòâ îêîëî 20-30ìèí.  íàø ñòàöèîíàð ïîñòóïèëà ñ äèàãíîçî ÎÍÌÊ ïî èøìè÷åñêîìó òèïó â êîðêîâûõ âåòâÿõ ëåâîé ÑÌÀ. ×àñòè÷íàÿ ìîòîðíàÿ àôàçèÿ. Îòëè÷èå â ýòîò ðàç òîëüêî â òîì, ÷òî ðå÷åâûå ð-âà äëèëèñü îêîëî 12 ÷àñîâ, äàæå ïîñëå êóïèðîâàíèÿ áîëåâîãî ïðèñòóïà. ÝÝÃ-î÷àã ýïèàãòèâíîñòè â ëåâîé ëîáíîé äîëå. ÌÐÒ-ïðîâåñòè íå óäàåòñÿ èç-çà òåõíè÷åñêèõ ïðîáëåì(àïïàðàò ñëîìàí). Âîïðîñ:1.Ñ êàêèì äèàãíîçîì âûïèñàòü:-ÎÍÌÊ ïî èøåìè÷åñêîìó òèïó â á.ëåâîé ÑÌÀ íà ôîíå ìèãðåíè ñ òèïè÷íîé(àôàòè÷åñêîé)àóðîé(ôîðìóëèðîâêà äèàãíîçà èç ñïðàâî÷íèêà ïîä ðåäàêöèåé Øòîêà è Ëåâèíà),èëè Ïåðñèñòèðóþùàÿ àóðà áåç èíôàðêòà.(äåëî â òîì ÷òî åñëè êàê ÿ ïîíèìàþ, ó ïàöèåíòêè ìèãðåíîçíûé èíôàðêò, òî àôàòè÷åñêèå ð-âà äîëæíû îñòàâàòüñÿ íà áîëåå äëèòåëüíûé ñðîê, à â äàííîì ñëó÷àå êëèíè÷åñêè áîëüøå äàííûõ çà ÒÈÀ-îòíîñèòüñÿ ëè ýòî ê äèàãíîçó-ìèãðåíîçíûé èíôàðêò???), ïðîùå ãîâîðÿ åñëè ðå÷ü èäåò î êëèíè÷åñêîé ÒÈÀ, òî âûðàæåíèå èíôàðêò íàâåðíîå íåïðàâîìî÷åí, à íåéðîâèçóàëèçàöèîííî ïîäòâåðäèòü íàëè÷èå èëè îòñóòñòâèå èíôàðêòà ÿ íå ìîãó. 2. Ìîæåò äåëî â ýïè-î÷àãå, íî ÿ íå íàøåë ïîäîáíîãî ýïè-ñèíäðîìà íå â îäíîé êëàññèèêàöèè? Ñ óàâæåíèåì Òèòîâ À.Â. âðà÷-íåâðîëîã. |
#2
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Åñëè ìîæåòå óòî÷íèòå:
1. Ãîëîâíàÿ áîëü ó ïàöèåíòêè òîëüêî ñ îäíîé ñòîðîíû? 2. Åñòü ëè íàðóøåíèÿ ñåðäå÷íîãî ðèòìà èëè ìûøå÷íàÿ ñëàáîñòü(óòîìëÿåìîñòü). Ïî ïîâîäó âàøèõ âîïðîñîâ: Èíôàðêò ìîæåò áûòü, à ìîæåò è íå áûòü: ÷àñòî áûâàåò äåëàåì ïàöèåíòó ñ ÒÈÀ ÌÐÒ à òàì èíôàðêò, åñëè êîìïëàéíñ ìîçãà ïîçîëÿåò, òî ïî÷åìó-áû è íåò (åùå îòåê èìååò çíà÷åíèå). Íóæíî ÌÐÒ ãîëîâíîãî ìîçãà. ps: À êàê êóïèðîâàëè ïðèñòóï è ÷åì ëå÷èòå? |
#3
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Çäðàâñòâóéòå,
Îäèí èç âàðèàíòîâ - ñèìïòîìàòè÷åñêàÿ ìèãðåíü (îáü¸ìíîå îáðàçîâàíèå, íàïðèìåð ÀÂÌ, ìîãëî áû îáüÿñíèòü êàê àôàçèþ, òàê è ýïèàêòèâíîñòü).Áåç íåéðîâèçóàëèçàöèè íå îáîéòèñü. Äðóãîé âàðèàíò, âîçìîæíî ïàöèåíòêà ñòðàäàåò êàêîé-ëèáî ðåäêîé ôîðìîé ìèãðåíè (åñëè áû èìåëà ìåñòî äèçàðòðèÿ - ìîæíî áûëî áû ïîäóìàòü î áàçèëÿðíîé ìèãðåíè), òàê æå èçâåñòíû ñëó÷àè ãåìèïëåãè÷åñêîé ìèãðåíè, áåç ãåìèïëåãèè: Arq Neuropsiquiatr. 1999 Mar;57(1):111-3. Links [Migraine with aphasia. Report of a family][Article in Portuguese] Almeida DB, Arruda WO, Ramina R, Pedrozo AA, Raskin S. Unidade de Ciencias Neurologicas, Hospital Vita Curitiba e Genetika, Brasil. We describe a Brazilian family in which one female patient and her three daughters present a clinical course compatible with migraine, preceded by language disorders (aphasia), without paresis. Several aspects related to genetics of migraine are reviewed. We conclude that further genetical studies are necessary to establish if these cases are different sources of well-known migraine subtypes as the familial hemiplegic migraine. Neurology. 1995 Jan;45(1):33-7. Links Familial hemiplegic migraine versus migraine with prolonged aura: an uncertain diagnosis in a family report.Marchioni E, Galimberti CA, Soragna D, Ferrandi D, Maurelli M, Ratti MT, Bo P, Montalbetti L, Albergati A, Savoldi F. Neurologic Institute C. Mondino, University of Pavia, Italy. Four of five members of a family complained of repeated attacks of hemiplegic migraine, migraine with aura of different types, or migraine without aura. The hemiplegia always outlasted the headache and was often accompanied by altered consciousness, aphasia, and, in one patient, coma; in this latter patient, the ictal EEG, recorded during two attacks, showed delta activity in the hemisphere contralateral to the hemiplegia. At least 2 months after their latest attacks, three patients showed dyscalculia, attentional disturbances, and impaired long-term verbal memory on neuropsychologic assessment. There were no cognitive disturbances in the unaffected relative. The severity of cognitive impairment appears to be correlated with migraine history. We attempt to classify these cases according to the criteria of the International Headache Society. Òàêèì îáðàçîì, ïî-ìîåìó, â ïåðâóþ î÷åðåäü õîðîøî áûëî áû âûÿñíèòü êàêàÿ èìåííî ìèãðåíü ó ïàöèåíòêè, à çàòåì ôîðìóëèðîâàòü äèàãíîç. Êñòàòè, Âû íè÷åãî íå íàïèñàëè î íàñëåäñòâåííîñòè(â öåëîì àíàìíåç î÷åíü êðàòêî), íåâðîëîãè÷åñêîì ñòàòóñå, äèíàìèêå, ýôôåêòèâíîñòè ïðîòèâîìèãðåíîçíîé òåðàïèè, ðåçóëüòàòàõ ëàá. àíàëèçîâ. |
#4
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Ïîíÿòíî, ÷òî áåç ÌÐÒ íå îáîéòèñü, íî êîëëåãå íóæíî âûïèñûâàòü ïàöèåíòêó ñåé÷àñ.
Ó÷èòûâàÿ äëèòåëüíîñòü ìåíåå 24 ÷àñîâ, ÿ áû íå ñòàë âûñòàâëÿòü äèàãíîç èíôàðêòà PS: Ïåðåíîøó òåìó â ôîðóì äëÿ âðà÷åé |
#5
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Äà åñòåñòâåííî áîëü îäíîé ñòîðîíû(ëåâàÿ ôðîíòîîðáèòàëüíàÿ îáëàñòü).Íàðóøåíèé ðèòìà è ìûøå÷íîé ñëàáîñòè íåò. Ïðèñòóï êóïèðîâàí â/â êàï ââåäåíèåì ñèáàçîíà è êîôåèíà ñ ïîñëåäóþùèì ââåäåíèåì ýóôèëëèíà.
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#6
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Îé, ÿ èìåë â âèäó äðóãîå: ðàíåå ó ïàöèåíòêè áîëåëà òîëüêî îäíà ñòîðîíà ãîëîâû èëè òî ñïðàâà, òî ñëåâà.  íàñòîÿùåå âðåìÿ îïèñàíî ìíîãî ñëó÷àåâ íàëè÷èÿ â àíàìíåçå ìèãðåíè, à ïîòîì ýòî îêàçûâàåòñÿ è ÀÂÌ è MELAS èòä.
Ïî ñóòè: Ñîãëàñåí ñ Michail åñëè íåâðîëîãè÷åñêàÿ ñèìïòîìàòèêà ðåãðåññèðîâàëà çà 24 ÷àñà çíà÷èò èíôàðêò íåëüçÿ ñòàâèòü â âàøåì ñëó÷àå. |
#7
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Íó íàñêîëêî ÿ çíàþ, ìèòîõîíäðèàëüíûå ýíöåôàëîïàòèè íà÷èíàÿñü â ðàííåì âîçðàñòå ïðîòåêàþò áîëåå çëîêà÷åñòâåííî, à òóò îäíà è òàæå ñèìïòîìàòèêà â ò÷åíèè 30 ëåò, è íè êàêèõ ïðèçíàêîâ äåãåíåðàòèâíîãî ïðîöåññà.
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#8
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MELAS ÿ ïðèâåë êàê ïðèìåð. Íà ñàìîì äåëå îïèñàíû íåñêîëüêî ñëó÷àåâ ïîçäíèõ äåáþòîâ MELAS ñàìûé ïîçäíèé 40 ëåò, à â àíàìíåçå ìèãðåíè Íî ýòî óæå ýêçîòèêà. Õîòÿ èìååò ïðàâî íà ñóùåñòâîâàíèå.
ps: Ëîâëþ ñåáÿ íà ìûñëè, ÷òî áåç ÌÐÒ ñëîæíî ðàáîòàòü. |
#9
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Ìíå êàæåòñÿ, íàäî ðàçäåëèòü äâå ïðîáëåìû: 1 ñ êàêèì äèàãíîçîì âûïèñàòü áîëüíóþ.
2. êàêèå ðåêîìåíäàöèè åé äàòü ïîñëå îáÿçàòåëüíîãî ïðîâåäåíèÿ ÌÐÒ è âåðèôèêàöèè äèàãíîçà. |
#10
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Ñîãëàñåí
Ñîãëàñåí ñ âàìè, áåç ÌÐÒ ðàáîòàòü ñëîæíî. Âûïèøó áîëüíóþ íàâåðíîå ñ äâîéíûì äèàãíîçîì:ÎÍÌÊ ïî òèïó ÒÈÀ â á.ëåâîé ÑÌÀ íà ôîíå ìèãðåíè ñ òèïè÷íîé (àôàòè÷åñêîé) àóðîé.
-Ïåðñèñòèðóþùàÿ àóðà áåç èíôàðêòà.(äàííóþ èíôîðìàöèÿ ïî÷åðïíóë èç ÌÊÃÁ). Ñ ðåêîìåíäàöèÿìè â ïðèíöèïå îïðåäåëèëñÿ. Ñïàñèáî âñåì ó÷àñíèêàì, êòî îòêëèêíóëñÿ íà ìîé çîâ. Íàäåþñü òàêæå áûòü âàì ïîëåçíûì, â ñëó÷àå ÷åãî.È èçâèíèòå, ÷òî îòíÿë òàê ìíîãî âðåìåíè ó âàñ íà òàêîé, â ïðèíöèïå ïóñòÿêîâûé âîïðîñ. |