Foreword: Second Congress of Croatian Stroke Society Drugi Kongres Hrvatskoga Dru Tva Za Prevenciju Mo Danog Udara

/cIo c||n C|coI, \c|. 41, Supp|.
3, 2002 7
Scconu Congrcss of Croaiian Sirokc Sociciy
Drugi kongrcs Hrvaiskoga urusiva za prcvcnciju mozuanog uuara
IORLWORD
Sirokc rcmains ihc ihiru mosi common causc of ucaih in ihc worlu, anu ihc lcauing causc of ucaih in ihc
Rcpublic of Croaiia. !n auuiiion, sirokc is also ihc lcauing causc of uisabiliiy in Croaiia anu worluwiuc. Wc arc fully
awarc of ihc faci ihai noi only olucr agc groups arc affccicu by sirokc, as inuiviuuals of ihc mosi prouuciivc agc havc
rcccnily bccn cvcr morc involvcu, making sirokc a grcai hcalih as wcll as cconomic problcm. Lpiucmiologic uaia
from ihc inuusirializcu counirics havc shown a uccrcasing ircnu in ihc sirokc morbiuiiy anu morialiiy ovcr ihc lasi
uccaucs of ihc pasi ccniury, which coulu bc uirccily aiiribuicu io ihc prcvcniivc mcasurcs implcmcnicu in ihcsc
counirics. !n conirasi, uaia for Croaiia poini io an incrcasc in ihc sirokc morbiuiiy anu morialiiy. A similar
unfavorablc icnucncy in ihc inciucncc of sirokc has also bccn rccorucu in oihcr Ccniral anu Lasi Luropcan
counirics as wcll as in a majoriiy of ucvcloping counirics. 1hcrcforc, an 'cpiucmic` of sirokc has bccn aniicipaicu io
occur in ihc uccaucs io comc. !i has bccn ucmonsiraicu ihai ihc managcmcni of sirokc paiicnis on appropriaicly
cguippcu warus (sirokc uniis) significanily rcuuccs ihc morialiiy anu uisabiliiy, whcrcas auuiiional uisabiliiy
rcuuciion can bc achicvcu by carly rchabiliiaiion of sirokc paiicnis. Ior ihc firsi iimc in hisiory, an cfficacious
ihcrapy for ischcmic sirokc has bccomc availablc wiih ihc usc of rccombinani iissuc plasminogcn aciivaior, howcvcr,
only wiihin 3 hours from ihc onsci of sirokc.
Unforiunaicly, noi all ncw conccpis havc yci bccn gcncrally acccpicu anu frcgucnily arc noi uscu in praciicc. !i
is ihcrcforc ncccssary io auurcsss boih mcuical profcssionals anu ihc populaiion ai largc io makc ihcm awarc ihai
sirokc is prcvcniablc by ihc consisicni usc of all mcihous of primary anu scconuary prcvcniion. Also, ii shoulu bc
rcpcaicu ovcr anu ovcr ihai sirokc is an cmcrgcncy conuiiion which rcguircs prompi mcuical ircaimcni in
appropriaicly cguippcu uniis.
1hc inicniion of ihc Iirsi Congrcss of ihc Croaiian Sociciy for Ncurovascular Disorucrs of ihc Croaiian Mcuical
Associaiion, anu Scconu Congrcss of ihc Croaiian Sociciy for Sirokc Ircvcniion, io bc hclu on Ociobcr 16-19, 2002,
in Osijck, Croaiia, is io prcscni ihc laicsi achicvcmcnis in ihc ficlus of cpiucmiology, prcvcniion anu uiagnosis of
sirokc, anu of ircaimcni anu rchabiliiaiion of sirokc paiicnis. ! uo hopc inuccu ihai prcscniaiions in ihc form of
plcnary lcciurcs anu posicrs will hclp in auopiing anu sprcau of ihc conccpis accoruing io which sirokc is an
cmcrgcncy mcuical conuiiion, anu ihai ii can bc boih prcvcnicu anu ircaicu. Only ihc joini, conccricu anu
pcrsisicni aciions of all of us will rcsuli in ihc rcuuciion of sirokc prcvalcncc, anu so climinaic sirokc from ihc
ignominous lcauing posiiion on ihc lisi of ihc causcs of morialiiy in Croaiia.
Vida Demarin, M.D., Ph.D.
Congress President
President of Croatian Stroke Society
President of Croatian Society for Neurovascular Disorders
8 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
Iirsi Congrcss of Croaiian Sociciy for Ncurovascular Disorucrs of Croaiian Mcuical Associaiion
Irvi kongrcs Hrvaiskoga urusiva za ncurovaskularnc porcmcajc Hrvaiskoga lijccnickog zbora
Mozuani uuar jc i naualjc irci uzrok smrinosii u svijciu, a prvi uzrok smrinosii u Rcpublici Hrvaiskoj. Uz io,
mozuani uuar jc prvi uzrok invaliunosii u nas i u svijciu. Svjcuoci smo i cinjcnicc ua mozuani uuar visc nc zahvaa
samo siarijc uobnc skupinc; zaunjih gouina ou mozuanog uuara obolijcvaju svc ccsc i bolcsnici u najprouukiivnijim
gouinama zivoia, sio ga cini vclikim kako zuravsivcnim iako i ckonomskim problcmom. Lpiucmioloski pouaci iz
zapaunih zcmalja pokazuju smanjivanjc morbiuiicia i morialiicia ou mozuanog uuara u zaunjim ucsciljcima
prosloga sioljca, sio jc izravna posljcuica prcvcniivnih akiivnosii. Nasuproi iomc, pouaci za Hrvaisku pokazuju
porasi morbiuiicia i morialiicia ou mozuanog uuara. Slican ncpovoljan ircnu porasia uccsialosii mozuanog uuara
biljczi sc i u osialim urzavama srcunjc i isiocnc Luropc, kao i u vcini zcmalja u razvoju, pa sc u uolazcim
ucsciljcima prcuvioa cpiucmija" mozuanog uuara. Dokazano jc ua sc zbrinjavanjcm bolcsnika u primjcrcno
oprcmljcnim oujclima (jcuinicc za mozuani uuar - stro/- er/ts) znacajno smanjuju morialiici i invaliunosi, a rano
zapocciom rchabiliiacijom bolcsnika s mozuanim uuarom moguc jc uouaino smanjiii invaliunosi. Io prvi puia u
povijcsii na raspolaganju nam jc ucinkoviio lijcccnjc ishcmijskog mozuanog uuara primjcnom rckombiniranog
ikivnog akiivaiora plazminogcna, ali samo unuiar prva iri saia ou nasianka mozuanog uuara.
Nazalosi, svc navcucnc spoznajc jos uvijck nisu opc prihvacnc i ccsio sc u praksi nc primjcnjuju. Sioga jc
nuzno poircbno mcou zuravsivcnim ujclainicima i u pucansivu siriii spoznaju ua sc mozuani uuar mozc sprijcciii
uosljcunom primjcnom svih mcioua primarnc i sckunuarnc prcvcncijc. 1akoocr, ircba sialno naglasavaii ua jc
mozuani uuar hiino mcuicinsko sianjc kojc zahiijcva hiian zuravsivcni irciman u primjcrcno oprcmljcnim jcuinicama.
Irvi kongrcs Hrvaiskoga urusiva za ncurovaskularnc porcmcajc Hrvaiskoga lijccnickog zbora i Drugi kongrcs
Hrvaiskoga urusiva za prcvcnciju mozuanog uuara, koji c sc ourzaii u Osijcku ou 16. uo 19. lisiopaua ovc gouinc,
ima za cilj prikazaii najnovija uosiignua u pourucju cpiucmiologijc, prcvcncijc i uijagnosiikc mozuanog uuara,
lijcccnja i rchabiliiacijc bolcsnika s mozuanim uuarom. Nauam sc ua cmo rauom u okviru plcnarnih prcuavanja i
kroz posicrc na ovom kongrcsu pomoi u prihvaanju i sircnju spoznaja ua jc mozuani uuar hiino mcuicinsko sianjc i
ua sc mozuani uuar mozc sprijcciii i lijcciii. Samo zajcunickim, upornim i uugoirajnim akcijama svih nas mozcmo
posiii smanjivanjc uccsialosi mozuanog uuara i na iaj nacin ukloniii mozuani uuar s ncslavnog prvog mjcsia uzroka
smrinosii u Hrvaiskoj.
Prof. dr. sc. Vida Demarin
Predsjednica Kongresa
Predsjednica Hrvatskoga drustva za prevenciju mozdanog udara
Predsjednica Hrvatskoga drustva za neurovaskularne poremecaje
IRLDGOVOR
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 9
LD!1OR!AL UVODN!K
STROK! - !IAGÔSTIC A^! TI!RAI!\TIC G\I!!II^!S
MOZ!AÎ \!AR - SMJ!RÎC! \ !IJAGÔSTICI I T!RAIIJI
Viua Dcmarin
Univcrsiiy Dcparimcni of Ncurology, Scsirc milosrunicc Univcrsiiy Hospiial,
Rcfcrcncc Ccnicr for Ncurovascular Disorucrs, Minisiry of Hcalih of ihc Rcpublic of Croaiia, Zagrcb, Croaiia
Klinika za ncurologiju, Klinicka bolnica Scsirc milosrunicc",
Rcfcrcnini ccniar za ncurovaskularnc porcmcajc Minisiarsiva zuravsiva Rcpublikc Hrvaiskc, Zagrcb
Nakon zavrscnc uckauc mozga mozuani uuar jc i naua-
ljc irci uzrok smrinosii u svijciu, a prvi uzrok smrinosii u
Rcpublici Hrvaiskoj. Mozuani uuar jc prvi uzrok invaliu-
nosii u nas i u svijciu. Zaunjih gouina ou mozuanog uuara
svc ccsc obolijcvaju i bolcsnici u najprouukiivnijim goui-
nama zivoia, sio ga cini svc vcim kako zuravsivcnim iako
i ckonomskim problcmom. Lpiucmioloski pouaci iz zapau-
nih zcmalja pokazuju smanjivanjc morbiuiicia i morialiicia
ou mozuanog uuara u zaunjim ucsciljcima prosloga sio-
ljca, sio jc izravna posljcuica prcvcniivnih akiivnosii. Na-
suproi iomc, pouaci za Hrvaisku pokazuju porasi morbiui-
icia i morialiicia ou mozuanog uuara. Ircvcncija jc jos
uvijck najbolji prisiup mozunom uuaru. Cilj prcvcncijc jc
smanjiii rizik nasianka mozuanog uuara ujclovanjcm na
cimbcnikc rizika. Najccsi cimbcnici rizika ukljucuju ncp-
rimjcrcnu prchranu, konzumiranjc alkohola, puscnjc,
smanjcnu ijclcsnu akiivnosi, hipcricnziju, sccrnu bolcsi,
poviscnc vrijcunosii kolcsicrola u scrumu, infarki miokar-
ua, airijsku fibrilaciju i karoiiunu sicnozu. U uijagnosiici
paiologijc mozuanc cirkulacijc uoplcrska jc sonografska
uijagnosiika posiala nczaobilaznom mciouom. Lksirak-
ranijski obojcni uoplcr i iranskranijski uoplcr omoguuju
brzu procjcnu ccrcbrovaskularnog siaiusa bolcsnika ic
prikaz raznih paioloskih sianja na krvnim zilama. Irciragc
su ncinvazivnc i mogu sc ponavljaii bcz rizika za bolcsni-
ka, cimc su posialc glavnom uijagnosiickom mciouom u
primarnoj prcvcnciji ccrcbrovaskularnih bolcsii, a pogounc
su i za primjcnu uz bolcsnicki krcvci. 1crapija ishcmijskog
mozuanog uuara zasniva sc na aniiagrcgacijskom lijcccnju
kojc sc prcporuca osobama s cimbcnicima rizika, nakon
iranziiomc ishcmijskc aiakc (1!A) ili mozuanog uuara, a
primjcnjujc sc i kou akuinog ishcmijskog mozuanog uuara,
Now, whcn ihc uccauc of brain has bccn cnucu, sirokc
siill rcmains ihc ihiru causc of ucaih in ihc worlu anu ihc
lcauing causc of ucaih in ihc Rcpublic of Croaiia. Also,
sirokc is ihc lcauing causc of uisabiliiy boih in ihc worlu
anu in Croaiia. Rcccnily, sirokc appcars io posc an cvcr
growing hcalih as wcll as cconomic problcm uuc io an
incrcasing prcvalcncc of sirokc in ihc mosi prouuciivc agc
groups.
Lpiucmiologic uaia from wcsicrn counirics poini io a
uccrcasc in ihc sirokc morbiuiiy anu morialiiy raics ovcr
ihc lasi uccaucs of ihc pasi ccniury, which has bccn ui-
rccily aiiribuicu io cfficicni prcvcniivc aciiviiics. !n con-
irasi, howcvcr, uaia for Croaiia show an incrcasc in ihc
sirokc morbiuiiy anu morialiiy raics.
Ircvcniion rcmains ihc bcsi approach io sirokc. 1hc
objcciivc of prcvcniivc mcasurcs is io rcuucc ihc risk of
sirokc by influcncing ihc risk faciors for sirokc. 1hc mosi
common risk faciors for sirokc incluuc inappropriaic ui-
ciary habiis, alcohol consumpiion, cigarciic smoking, in-
aucguaic physical aciiviiy, hypcricnsion, uiabcics mclli-
ius, clcvaicu scrum cholcsicrol, myocaruial infarciion,
airial fibrillaiion, anu caroiiu sicnosis.
!n ihc uiagnosis of ccrcbral circulaiion paihology, uop-
plcr sonography has bccomc an inuispcnsablc iool. Lxirac-
ranial color uopplcr anu iranscranial uopplcr allow for rapiu
cvaluaiion of ihc paiicni`s ccrcbrovascular siaius anu vi-
sualizaiion of various ccrcbrovascular paihologic conui-
iions. 1hcsc cxaminaiions arc noninvasivc, can bc rcpcai-
cu wiihoui paiicni risk cxposurc, anu can bc pcrformcu
ai bcusiuc, ihus having bccomc ihc main uiagnosiic mcih-
ou in primary prcvcniion of ccrcbrovascular uiscascs.
10 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
uok sc aniikoagulanina icrapija inuicira u poscbnim sluca-
jcvima akuinog ishcmijskog mozuanog uuara, a u sckunuar-
noj prcvcnciji nalazi mjcsio kou ourcocnih srcanih bolcsii
(airijska fibrilacija). Kou simpiomaiskih bolcsnika sa znacaj-
nom sicnozom karoiiunih aricrija kirurski jc zahvai icrapija
izbora. Unazau nckoliko gouina u brojnim zapaunim zcm-
ljama u lijcccnju akuinog ishcmijskog mozuanog uuara
primjcnjujc sc iromboliza (riIA). Lijcccnjc sc provoui po
iocno ourcocnom proiokolu, jcr svako ousiupanjc uonosi
vclik rizik komplikacija. Maua jc irombolizu moguc
provcsii samo u malobrojnih bolcsnika, ona jc puiokaz ua
icrapija ishcmijskog mozuanog uuara posioji i ua ircba
naglasavaii poircbu prompinc rcakcijc bolcsnika, njcgovc
okolinc i mcuicinskog osoblja. Uz najnovija isirazivanja
usmjcrcna ka poipomaganju irombolizc pomou kon-
iinuiranog moniioriranja iranskranijskim uoplcrom (1CD-
om) provouc sc brojna isirazivanja koja imaju za cilj urgcni-
no ujclovaii na pcnumbru. Dokazano jc ua sc zbrinjavan-
jcm bolcsnika u pri-mjcrcno oprcmljcnim oujclima (jcuin-
icc za mozuani uuar - stro/- er/ts) cak i bcz primjcnc irom-
bolizc znacajno sma-njuju smrinosi i invaliunosi. Sioga jc
ncophouna rcorganizacija mcuicinskc sluzbc kako bi sc
mozuani uuar shvaiio kao hiino sianjc kojc zahiijcva hiian
iranspori u primjc-rcno oprcmljcnu usianovu.
Usprkos naprciku u zbrinjavanju bolcsnika s mozuanim
uuarom bolcsnici nakon prcboljclog mozuanog uuara vrlo
ccsio imaju icska osiccnja i funkcionalna ograniccnja krci-
anja i pcrccpcijc. Rchabiliiacija jc kljucna u zbrinjavanju
bolcsnika s prcboljclim mozuanim uuarom. Rano zapocc-
iom rchabiliiacijom moguc jc uouaino smanjiii invaliu-
nosi. !ako rchabiliiacijski programi nc mijcnjaju ncurolos-
ki ucficii bolcsnika, mogu znacajno priuonijcii osamosial-
jivanju bolcsnika. Rchabiliiaciju bi ircbao provouiii mul-
iiuisciplinarni iim sirucnjaka. Bolcsnici i clanovi njihovih
obiiclji moraju biii ukljuccni u rchabiliiacijski iim. Nakon
zavrscnc uckauc mozga mozcmo rci ua ncurologija biljczi
znacajan naprcuak u zbrinjavanju bolcsnika s mozuanim
uuarom. S obzirom na mnogobrojna isirazivanja koja su u
iijcku, za nauaii sc jc ua c buuunosi uonijcii jos vcc
iskorakc.
1hc ircaimcni of ischcmic sirokc is bascu on aniiag-
grcgaiion ihcrapy ihai is rccommcucu for paiicnis wiih risk
faciors aficr iransicni ischcmic aiiack (1!A) or sirokc, anu
is also uscu in acuic ischcmic sirokc, whcrcas aniicoagu-
lani ihcrapy is inuicaicu in spccific cascs of acuic ischcm-
ic sirokc, anu in scconuary prcvcniion in ihc prcscncc of
somc caruiac uiscascs (airial fibrillaiion). !n sympiomaiic
paiicnis wiih significani caroiiu aricrial sicnosis, surgical
proccuurc is ihcrapy of choicc.
1hrombolysis (riIA) has for scvcral ycars now bccn
uscu in many wcsicrn counirics in ihc managcmcni of
acuic ischcmic sirokc. 1hc ircaimcni is pcrformcu siricily
following ihc csiablishcu proiocol, bccausc any mouifica-
iion is associaicu wiih a high risk of complicaiions. Al-
ihough ihrombolysis can only bc uonc in a small propor-
iion of paiicnis, ii clcarly shows ihai sirokc is amcnablc
io ircaimcni anu ihai ihc nccu of prompi rcaciion by ihc
paiicni, his cnvironmcni anu mcuical pcrsonncl shoulu bc
cmphasizcu. !n auuiiion io ihc laicsi rcscarch inio ihrom-
bolysis suppori by coniinuous iranscranial Dopplcr (1CD)
moniioring, numcrous siuuics aimcu ai cmcrgcncy inicr-
vcniion on ihc pcnumbra havc bccn unucr way.
!i has bccn ucmonsiraicu ihai sirokc morialiiy anu
uisabiliiy raics can bc consiucrably rcuuccu by ihc man-
agcmcni of sirokc paiicnis in appropriaicly cguippcu uniis
(sirokc uniis), howcvcr, such a conccpi obviously cniails
ihc nccu of hcalih carc rcsiruciuring. Sirokc shoulu bc
rccognizcu as an cmcrgcncy siaic ihai rcguircs cmcrgcn-
cy iransporiaiion io an appropriaicly cguippcu insiiiuiion.
!n spiic of ihc auvanccs mauc in ihc carc of sirokc
paiicnis, ihcy frcgucnily suffcr scvcrc lcsions anu func-
iional rcsiriciions of movcmcni anu pcrccpiion. Rchabil-
iiaiion is crucial in ihc carc of sirokc paiicnis. 1hc grauc
of uisabiliiy can bc auuiiionally rcuuccu by carly rchabili-
iaiion. Alihough rchabiliiaiion programs will noi mouify
ihc paiicni`s ncurologic ucficii, ihcy may consiucrably
coniribuic io ihc paiicni`s rcgaining inucpcnucncc. Rc-
habiliiaiion shoulu bc pcrformcu by a muliiuisciplinary
icam of profcssionals, which shoulu also incluuc ihc pa-
iicnis anu ihcir family mcmbcrs.
Upon ihc complciion of ihc uccauc of brain, wc can
siaic ihai ncurology has achicvcu consiucrablc auvancc-
mcnis in ihc carc of sirokc paiicnis. Consiucring ihc many
rcscarchcs ihai arc unucr way, ihc fuiurc will hopcfully
bring cvcn grcaicr sicps forwaru.
Rcfcrcnccs / Iitcruturu
1. WARLOW CI. Lpiucmiology of sirokc. Lancci 1997;352 (Suppl
!!!):1-4.
2. DLMAR!N V. Sirokc - prcscni siaic anu pcrspcciivcs. Luiiorial. Ic-
riou Biol 1995;2:95-7.
3. DLMAR!N V, LOVRLNC!C-HUZ]AN A, SLR!C V, VARGLK-
SOL1LR V, 1RKAN]LC Z, VUKOV!C V, LUIRL1 V, KALOUSLK
M, DL SYO D, KADO]!C D, D!KANOV!C M, V!1AS M. Rccom-
mcnuaiions for sirokc managcmcni. Acia Clin Croai 2001;40:127-
54.
4. BRA!N!N M, BORNS1L!N N, BOYSLN G, DLMAR!N V. Acuic
ncurological sirokc carc in Luropc: rcsulis of ihc Luropcan Sirokc
Carc !nvcniory. Lur ] Ncurol 1999;7:5-10.
5. DLMAR!N V. Lmcrging siraicgics in ihc prcvcniion anu uiagnosis
of sirokc. Acia Clin Croai 1997;36 (Suppl):7-17.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 11
1hc Worlu Hcalih Organizaiion ucfincs sirokc as a
rapiu ucvclopmcni of clinical signs of focal (or global)
impairmcni of brain funciions, wiih sympioms lasiing for
24 hours or longcr, or lcauing io ucaih, wiihoui any oihcr
obvious causc apari from ihc signs of vascular uamagc". !n
clinical praciicc, ihc classificaiion iaking ihc paihoanaiom-
ical anu paihophysiological paramcicrs in consiucraiion,
anu uiffcrcniiaiing hcmorrhagic sirokc ihai occurs in 157
- 207 anu ischcmic sirokc accouniing for 807 - 857 of
cascs, has bccn wiucly acccpicu. Hcmorrhagic sirokc is
furihcr uiviucu inio ihc subiypcs of iniraccrcbral hcmor-
rhagc of iypical or aiypical localizaiion, accouniing for somc
157, anu subarachnoiu hcmorrhagc (SAH), occurring in
somc 57 of all sirokc cascs. !schcmic sirokc is uiviucu inio
ihc following subiypcs: ihromboiic, cmbolic, anu hcmo-
uynamic sirokc. Accoruing io ihc !nicrnaiional Classifici-
aiion of Discascs, ccrcbrovascular uiscascs arc caicgorizcu
in a similar way, wiih ihc following subgroups cncoucu !60
- !69: SAH, iniraccrcbral hcmorrhagc, oihcr noniraumai-
ic hcmorrhagcs, ccrcbral infarciion causcu by cxiraccrcbral
or iniraccrcbral occlusion, anu nonspccific sirokc. Rcccnily,
a praciical 1OAS1 classificaiion of ischcmic sirokc has
bccn wiucly uscu, uiffcrcniiaiing ihc following caicgorics:
largc bloou vcsscl infarcis, lacunar infarcis, caruiocmbolic
infarcis, infarcis uuc io oihcr causcs, anu infarcis of un-
known causc.
!i has bccn csiimaicu ihai aboui 4 million pcoplc suf-
fcr sirokc in ihc worlu p-r ycar, somc 570,000 of ihcsc in
LllDLMlCLCC Cl S1kClL
LllDLMlCLCCl}A MCZDANCC UDAkA
Svjciska zuravsivcna organizacija ucfinira mozuani uuar
(MU) kao naglo razvijanjc klinickih znakova fokalnog (ili
globalnog) porcmcaja mozuanih funkcija, sa simpiomima
koji iraju 24 saia ili uuzc, ili vouc k smrii, bcz urugog jas-
nog uzroka, osim znakova osiccnja krvnih zila". U klin-
ickom rauu siroko jc prihvacna klasifikacija koja uzima u
obzir paiolosko-anaiomskc i paiofizioloskc paramcirc, ic
razlikujc hcmoragijski mozuani uuar (HMU) koji sc javlja
u 157-207 i ishcmijski mozuani uuar (!MU) koji cini 807-
857 slucajcva. Iouiipovi HMU-a su: iniraccrcbralna
hcmoragija iipicnc ili aiipicnc lokalizacijc, koja prcusiavl-
ja oko 157 ic subarahnoiuna hcmoragija (SAH) koja prcu-
siavlja oko 57 slucajcva MU-a. Iouiipovi !MU-a su: irom-
boiski, cmbolijski i hcmouinamski uuar. Mcounarouna kla-
sifikacija bolcsii razvrsiava ccrcbrovaskularnc bolcsii (CVB)
na priblizno isii nacin, navouci pou siframa ! 60-! 69 pou-
skupinc: SAH, iniraccrcbralno krvarcnjc, osiala ncirau-
maiska krvarcnja, ccrcbralni infarki uzrokovan cksiraccrc-
bralnom ili iniraccrcbralnom okluzijom, ic ncspccificirani
mozuani uuar. Irakiicna jc i u zaunjc vrijcmc u siroj upo-
rabi klasifikacija !MU-a 1OAS1 koja razlikujc sljcucc
kaicgorijc: infarkic vclikih krvnih zila, lakunarnc infarkic,
kauiocmbolijskc infarkic, infarkic koji su posljcuica urugih
uzroka, ic infarkic ncpoznaiog uzroka. Irocjcnjujc sc ua u
svijciu na gouinu ou MU-a oboli oko 4 milijuna ljuui. Ou
ioga na Luropu oipaua oiprilikc 570.000, a na Sjcuinjcnc
Amcrickc Drzavc oko 500.000 oboljclih. U prikazu inciucn-
cijc MU-a obicno sc rabc uobno sianuaruiziranc siopc (c--
Main 1opic ! !. glavna icma
!II!!MIOIOGY OI STROK!
!II!!MIOIOGIJA MOZ!AÔG \!ARA
Draguiin Kauoji
Univcrsiiy Dcparimcni of Ncurology, Osijck Univcrsiiy Hospiial, Osijck, Croaiia
Klinika za ncurologiju, Klinicka bolnica Osijck, Osijck
12 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
stcrdcrd/c-d /r/d-r- rct-s). Mcounarounc cpiucmioloskc
siuuijc pokazuju ua siopc inciucncijc rasiu cksponcncijalno
s uobi, ic sc krcu izmcou 0,3 promila u irccm i ccivriom
ucsciljcu zivoia, svc uo 30 promila u osmom i ucvciom
ucsciljcu zivoia, sio u prosjcku iznosi 1-2 promila. Siopc
prcvalcncijc MU-a u svijciu variraju izmcou 5 promila i
nckoliko posioiaka. Irocjcnjujc sc ua oiprilikc jcuna ircina
oboljclih ou mozuanog uuara umirc, uruga ircina ima iczi,
a irca ircina laksi rcziuualni ncuroloski ucficii ili jc bcz
ucficiia. Cimbcnici koji prcuvioaju losu prognozu i ishou
MU-a su: visoka zivoina uob, muski spol, posiojanjc uija-
bcicsa, aricrijskc hipcricnzijc i srcanc bolcsii u oboljclih,
icmpcraiura, uisfagija, inkoniincncija, pogorsanjc svijcsii,
iczak ncuroloski ucficii, kogniiivni porcmcaji, lokalizacija
i vclicina infarkia, cucm i pomak srcuisnjih sirukiura,
biokcmijski i hcmaioloski porcmcaji iiu. Smrini ishou
MU-a uzrokuju srcuisnjc i pcrifcrnc komplikacijc. Najccsc
srcuisnjc komplikacijc su: ccrcbralni cucm, iransicniori-
jalna hcrnijacija, hcmoragijska iransformacija ishcmijc,
cpilcpiicni napauaji, ucprcsija. Znaino ccsc smri bolcsni-
ka s MU-om uzrokuju pcrifcrnc (sisicmskc) komplikacijc:
uuboka vcnska iromboza i pluna cmbolija, bronhopncu-
monija, urinarni infcki, scpiikcmija, aspiracija, srcana arii-
mija, miociioliza, nckonirolirana hipoicnzija, nagla smri.
Siopc smrinosii ou MU-a u Luropi znacajno sc razlikuju.
Najvisc siopc ou 249 umrlih/100.000 sianovnika
zabiljczcnc su u Bugarskoj, a najnizc ou 27/100.000
sianovnika u Svicarskoj. !siocnocuropskc zcmljc imaju visu
ukupnu smrinosi, uok su najnizc siopc zabiljczcnc u skan-
uinavskim zcmljama, Svicarskoj i Nizozcmskoj. Siopc
smrinosii uramaiicno su smanjcnc iijckom zaunjih ncko-
liko ucsciljca u ]apanu i zapaunocuropskim zcmljama.
Nasuproi iomc, u isiocnocuropskim zcmljama u iom
razuoblju biljczi sc sialan porasi siopc smrinosii ou MU-
a, sio sc nasiavlja i u uvjciima iranzicijc ovih zcmalja. Ou
osobiiog su znaccnja siuuijc kojc pokazuju sckularnc
promjcnc u morialiiciu ou nckc bolcsii kroz uugo razuobljc
gouina ili ucsciljca. Ncurocpiucmioloskc siuuijc MU-a
vrlo su vaznc za ispravno programiranjc i planiranjc
zuravsivcnc sluzbc i njczinc spccificnc organizacijc. Usio,
onc omoguuju poipunijc saglcuavanjc prirounog iijcka
bolcsii, uzroka bolcsii, ic prosuubu uijccaja gcnciski ourc-
ocnih i cgzogcnih cimbcnika na pojavu i razvoj bolcsii.
Luropc anu 500,000 in ihc Uniicu Siaics of Amcrica. On
prcscniing ihc inciucncc of sirokc, ihc agc-sianuaruizcu
inciucncc raics arc gcncrally uscu. !nicrnaiional cpiucmi-
ologic siuuics show ihc inciucncc raics io risc cxponcn-
iially wiih agc, ranging bciwccn 0.3/ in ihc ihiru anu
fourih uccauc of lifc io up io 30/ in ihc cighih anu ninih
uccauc of lifc, or 1-2/ on an avcragc.
1hc prcvalcncc of sirokc in ihc worlu varics bciwccn
5/ anu a fcw pcrccniagc. !i is csiimaicu ihai approxi-
maicly onc ihiru of sirokc paiicnis uic, onc ihiru suffcr
scvcrc ncurologic ucficiis, anu onc ihiru havc milu rcsiu-
ual ncurologic ucficii or arc frcc from ii. 1hc faciors prc-
uiciivc of poor sirokc prognosis anu ouicomc arc: auvanccu
agc; malc scx; prcscncc of uiabcics mclliius, hypcricnsion,
or caruiac uiscasc; icmpcraiurc; uysphagia; inconiincncc;
consciousncss uisiurbancc; scvcrc ncurologic ucficii; cog-
niiivc uisorucrs; localizaiion anu sizc of infarciion; cucma
anu shifi of ccniral siruciurcs; biochcmical anu hcmaio-
logic uisorucrs, cic.
A faial ouicomc of sirokc is uuc io ccniral anu pcriph-
cral complicaiions. 1hc mosi common ccniral complica-
iions arc: ccrcbral cucma, iransicniorial hcrniaiion, hcm-
orrhagic iransformaiion of ischcmia, cpilcpiic scizurcs, anu
ucprcssion. !n sirokc paiicnis, ucaih is much morc frc-
gucnily causcu by pcriphcral (sysicmic) complicaiions
such as uccp vcnous ihrombosis anu pulmonary cmbolism,
bronchopncumonia, urinary infcciion, scpiiccmia, aspira-
iion, caruiac arrhyihmia, myocyiolysis, unconirollcu hy-
poicnsion, anu suuucn ucaih.
!n Luropc, ihc morialiiy raics for sirokc grcaily vary. 1hc
highcsi sirokc morialiiy raic of 249 ucaihs p-r 100,000 in-
habiianis has bccn rccorucu in Bulgaria, anu ihc lowcsi raic
of 27 ucaihs p-r 100,000 inhabiianis in Swiizcrlanu. Lasi
Luropcan counirics havc a highcr ioial morialiiy raic, whcrc-
as lowcsi raics havc bccn rcporicu from Scanuinavian coun-
irics, Swiizcrlanu anu ihc Ncihcrlanus. Ovcr ihc lasi fcw
uccaucs, sirokc morialiiy raics havc bccn uramaiically rc-
uuccu in ]apan anu Wcsicrn Luropc. !n conirasi, a consiani
incrcasc in ihc sirokc morialiiy raics has bccn rccorucu in
Lasi Luropcan counirics, anu has bccn obscrvcu io coniin-
uc in ihc conuiiions of iransiiion in ihcsc counirics. 1hc
siuuics showing sccular changcs in a uiscasc morialiiy ovcr
ycars or uccaucs arc of spccial imporiancc.
Ncurocpiucmiologic siuuics of sirokc havc a significani
rolc for corrcci programming anu planning of hcalih carc
anu iis spccific organizaiion. Also, ihcsc siuuics proviuc a
comprchcnsivc insighi inio ihc naiural coursc of ihc uis-
casc, causc of ihc uiscasc, anu allow for ihc cffccis of gc-
nciically ucicrmincu anu cxogcnous faciors on ihc occur-
rcncc anu ucvclopmcni of ihc uiscasc io asscss.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 13
AKTI\ÔSTI ZÂ^ST\!Ô-ISTRAZI\ACK! GR\I!
ZA ORGAÎZACIJ\ ^!\ROIOSK! SI\ZH! S\J!TSK!
^!\ROIOSK! I!!!RACIJ! \ IIJ!C!^J\ I IR!\!^CIJI
C!R!HRO\ASK\IARÎI HOI!STI
TI! ACTI\ITI!S OI TI! WI^ RG O!^S I^ TI!
MAÂG!M!^T A^! IR!\!^TIO^ OI C!R!HRO\ASC\IAR
!IS!AS!S
Bosko Barac
Irofcssor of Ncurology cm, Iaculiics of Mcuicinc, Univcrsiiics of Zagrcb anu Osijck; Honorary mcmbcr of Amcrican
Acaucmy of Ncurology, Mcmbcr of Acaucmy of Mcuical Scicnccs of Croaiia; Chairman of WIN Rcscarch Group on
Organizaiion anu Dclivcry of Ncurological Scrviccs
Irofcsor ncurologijc Mcuicinskih fakulicia Svcucilisia u Zagrcbu i Osijcku u m., Iocasni clan Amcrickc ncuroloskc
akaucmijc, Rcuovni clan Akaucmijc mcuicinskih znanosii Hrvaiskc, Ircusjcunik Znansivcno-isirazivackc grupc za
organizaciju ncurologijc Svjciskc ncuroloskc fcucracijc
Ou svojcga osnuika 1989. gouinc Znansivcno-isira-
zivacka grupa za organizaciju ncuroloskc sluzbc (Z!G)
Svjciskc ncuroloskc fcucracijc (SNI) siavila si jc u srcuisic
zanimanja masovnc ncuroloskc bolcsii" kojc sc mogu us-
pjcsno lijcciii i prcvcniraii, s poziiivnim ounosom cijcnc
i korisnosii". Zbog ioga su ccrcbrovaskularnc bolcsii (CVB)
bilc u sialnom zarisiu ujclovanja Z!G. Na nckoliko sasiana-
ka i konfcrcncija bili su naglascni cimbcnici prcsuuni za
planiranjc svcobuhvainc brigc za prcvcnciju i lijcccnjc
CVB. Iromjcnc u smrinosii ou mozuanog uuara (MU)
mogu biii rczuliai promjcna u inciucnciji MU ili lcialiicia
oboljclih. U nckoliko siuuija iz razvijcnih zcmalja izvjcsia-
vano jc o pauu lcialiicia oboljclih, uok jc smanjivanjc in-
Sincc iis founuaiion in 1989, ihc Worlu Icucraiion of
Ncurology Rcscarch Group on Organizaiion anu Dclivcry
of Ncurological Scrviccs (WIN RG ODNS) has in iis ccn-
icr of inicrcsi ihc mass ncurological uiscascs", which can
bc succcssfully ircaicu anu prcvcnicu, wiih clcar cosi -
bcncfii" raiios. Ior ihis rcason, ihc ccrcbrovascular uiscascs
(CVD) wcrc in a consiani focus of ihc RG. On scvcral
mcciings anu confcrcnccs, faciors imporiani for ihc plan-
ning of comprchcnsivc carc for CVD wcrc sircsscu.
Changcs in sirokc morialiiy may rcsuli from changcs
in sirokc inciucncc or casc faialiiy. Scvcral siuuics from
ucvclopcu counirics havc rcporicu a fall in casc faialiiy,
whilc ihc ucclinc in ihc inciucncc of sirokc has sioppcu
1. WHO MON!CA Irojcci, Irincipal invcsiigaiors. 1hc Worlu Hcalih
Organisaiion MON!CA Irojcci (moniioring ircnus anu ucicrmi-
nanis in caruiovascular uiscasc): a major inicrnaiional collaboraiion.
] Clin Lpiucmiol 1988;41:105-14.
2. Worlu Hcalih Organizaiion. !nicrnaiional classificaiion of uiscascs
anu rclaicu hcalih problcms, 1cnih Rcvision. Gcncva: Worlu Hcalih
Organizaiion, 1992.
3. ADAMS IH, BLND!XLN B, KAIILLLL ], B!LLLR ], LOVL B,
GORDON D, MARSH R, 1OAS1 !nvcsiigaiors. Classificaiion of
subiypcs of acuic ischcmic sirokc. Sirokc 1993;24:35-41.
4. BON!1A R. Lpiucmiology of sirokc. Lancci 1992;339:342-4.
5. BON!1A R, BLAGLLHOLL R, NOR1H ]DK. Lvcni, inciucncc
anu casc-faialiiy raics of ccrcbrovascular uiscasc in Aucklanu, Ncw
Zcalanu. Am ] Lpiucmiol 1984;120: 236-43.
6. BON!1A R, S1LWAR1 A, BLAGLLHOLL R. !nicrnaiional ircnus
in sirokc morialiiy: 1970-1985. Sirokc 1990;21:989-92.
7. 1HORVALDSLN I, -t c/. Sirokc ircnus in ihc WHO MON!CA
Irojcci. Sirokc 1997;28:500-6.
14 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
ciucncijc uuara prcsialo ili sc cak ociiovao i ourcocn po-
rasi inciucncijc. Siuuijc iz !siocnc Luropc pokazalc su po-
vcanu inciucnciju, uok ircnuovi lcialiicia oboljclih nisu
pokazivali ujcunaccnosi. 1crci ou MU c u gouinama iza
2000. vjcrojaino i ualjc rasii zbog siarcnja sianovnisiva. U
Z!G jc bio prihvacn ncurocpiucmioloski prisiup u prc-
vcnciji MU, sio ga jc prculozio Gorclick. Kako uujcl siari-
jih osoba sialno rasic, razumijcvanjc ircnuova morbiuiic-
ia i morialiicia MU jc vazno za planiranjc sluzbi javnog
zuravsiva i pouuzimanjc mjcra za konirolu uuara. MU jc
priklauan za prcvcnciju buuui ua ima visoku prcvalcnciju
i prcusiavlja visok urusivcni icrci i visoku ckonomsku
cijcnu, a omoguujc sigurnc prcvcniivnc mjcrc kojc mogu
uovcsii uo znacajnih ckonomskih usicua i smanjcnja ljuu-
skih painji. Dvijc su glavnc siraicgijc za prcvcnciju MU:
a) masovni prilaz" (ocss cpproc/) naglasava promjcnu
nacina zivoia kako bi sc posiiglo umjcrcno snizcnjc razinc
cimbcnika rizika kou svih pojcuinaca u populaciji. Irimjcr
ukljucujc ougovarajuu uijciu za smanjcnjc visokog ilaka,
kolcsicrola i razinc masii u hrani, ograniccnjc poirosnjc
icskih alkoholnih pia, prcsianak puscnja, ic promovira-
njc zuravog nacina zivoia u ciljnoj populaciji. Ovi naprcici
sc posiizu siroko zasnovanim mjcrama u zajcunici, po uzoru
na finsko iskusivo, uz praicc zakonouavnc i ckonomskc
mjcrc; b) prilaz bolcsnicima visokog rizika" iucniificira
osobc s visokim razinama cimbcnika rizika u zajcunici. U
nacclu jc ovujc poircbno spccificno inuiviuualno lijcccnjc
za znacajnijc snizcnjc posiojcih cimbcnika rizika u
ugrozcnog bolcsnika. Oba prilaza, masovni" i visokog
rizika", komplcmcniarni su u uspjcsnoj prcvcnciji MU.
ZukIjucci:
1. Z!G naglasava poircbu sialnih ncurocpiucmioloskih
siuuija na rcgionalnoj i lokalnoj razini u cilju boljcg razumi-
jcvanja i pronalazcnja prisuinih i lokalno uominaninih ri-
zicnih i ciioloskih cimbcnika CVB koji ourcouju gcnczu i
razvoj spccificnih oblika CVB u isirazivanoj populaciji. 1o
c omoguiii boljc razumijcvanjc posiojcih vclikih razlika
u cnuogcnim, ali jos visc u cgzogcnim cimbcnicima rizika;
2. Suraunja na nacionalnoj i mcounarounoj razini mozc
osiguraii pronalazcnjc najboljc moguc i najracionalnijc,
lokalno korisiivc siraicgijc u prcvcnciji i ranom oikrivanju
CVB prcma opisanom ncurocpiucmioloskom nacclu kojc
uajc najboljc rczuliaic u ounosu cijcnc i korisnosii, a na
icmcljima nascg razumijcvanja razlicnosii mciouologija
kojc rabimo u masovnom" i prilazu visokog rizika";
3. Irculazc sc uporaba rclaiivno jcfiinih mcioua za
poircbc primarnog inuiviuualnog probiranja" (sr--r/r):
klinickc ncurofizioloskc (LLG i urugc), biokcmijskc i ncu-
rosonografskc mciouc icmcljcnc na klinickim i ncuropi-
ucmioloskim pouaicima;
anu cvcn somc incrcasc has bccomc cviucni. Siuuics from
Lasicrn Luropc havc shown an incrcascu inciucncc, whilc
ihc ircnus for casc faialiiy havc noi bccn uniform. 1hc
social burucn of sirokc will probably coniinuc io incrcasc
bcyonu 2000 uuc io ihc aging of ihc worlu populaiion.
A ncurocpiucmiological approach io ihc problcms cn-
counicrcu in sirokc prcvcniion has bccn acccpicu by ihc
RG, as proposcu by Gorclick. As ihc proporiion of ihc clu-
crly riscs in our populaiions, unucrsianuing of ircnus in
sirokc morialiiy anu morbiuiiy is imporiani for planning
public hcalih scrviccs anu mcasurcs io conirol sirokc.
Sirokc is wcll suiicu for prcvcniion as ii has a high prcva-
lcncc anu social burucn of illncss, high cconomic cosi, anu
safc anu cffcciivc prcvcniion mcasurcs capablc io prcvcni
sirokc, lcauing io subsianiial cconomic savings anu rcuuc-
iion in human suffcring.
1hcrc arc iwo major siraicgics io prcvcni sirokc: (a)
'mass approach` cmphasizcs lifcsiylc mouificaiion io
achicvc moucsi rcuuciions in ihc lcvcl of a risk facior in
all inuiviuuals in ihc populaiion. Lxamplcs incluuc prop-
cr uici io lowcr hypcricnsion, cholcsicrol anu fai iniakc,
rcsiriciion in hcavy alcohol consumpiion, smoking ccssa-
iion, anu promoiion of oihcr hcalihy lifcsiylc bchaviors in
ihc iargci populaiion. 1hcsc arc auvanccu ihrough com-
muniiy-wiuc hcalih cuucaiion, lcgislaiion anu cconomic
mcasurcs, as ucscribcu in Iinlanu; (b) 'high-risk approach`
iucniifics pcrsons in ihc communiiy wiih high lcvcls of risk
faciors. Highly spccific mcuicaiion is rcguircu io achicvc
subsianiial rcuuciions of ihc risk faciors in an inuiviuual
paiicni. 1hc mass anu high-risk approachcs arc consiucrcu
complcmcniary for prcvcniion.
ConcIusions:
1. Coniinuous ncurocpiucmiological siuuics on rcgion-
al anu local scalc arc nccucu in orucr io obiain bciicr
unucrsianuing anu finu ihc iruly rcprcscnicu, locally uom-
inani risk anu ciiologic faciors, ucicrmining ihc gcncsis
anu furihcr ucvclopmcni of CVD in ihc invcsiigaicu pop-
ulaiion, wiih uuc consiucraiion of ihc grcai uiffcrcnccs in
ihc inirinsic anu cxirinsic risk faciors.
2. Collaboraiivc cfforis on naiional anu inicrnaiional
lcvcls arc nccucu io finu ihc bcsi possiblc, mosi raiional,
locally applicablc siraicgy in ihc prcvcniion anu carly uc-
icciion of CVD accoruing io ihc ucscribcu ncurocpiucmi-
ological approachcs, giving ihc bcsi cosi-cffcciivcncss ra-
iio, consiucring ihc uiffcrcni mcihouologics uscu in mass
approach anu high-risk approach.
3. 1hc RG ODNS proposcs usagc of ihc rclaiivcly in-
cxpcnsivc mcihous in primary inuiviuual scrccning: clin-
ical ncurophysiological (LLG anu oihcrs), biochcmical anu
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 15
4. Irculazc sc primjcna spccificnih prcvcniivnih i ic-
rapijskih mcioua u nasoj icznji oulaganja CVB i MU za kas-
nijc razuobljc covjckova zivoia, kau jc i koliko jc io moguc
u ourcocnoj zajcunici;
5. 1akoocr sc prcporuca uporaba moucrnih, znansivcno
poipuno uicmcljcnih mcioua lijcccnja hipcrakuinog
MU", na icmclju razumijcvanja paiofiziologijc ovc ccrc-
brovaskularnc kaiasirofc, primjcnjujui najboljc lokalno
primjcnjivo lijcccnjc uz uporabu izv. icrapijskog prozora";
6. Organiziraii najbolju lokalno primjcnjivu siraicgiju
u primarnoj i sckunuarnoj prcvcnciji, ranoj uijagnozi, naj-
boljcm mogucm lijcccnju, ic u rchabiliiaciji, ncuroloskoj
rcsiiiuciji i rcsocijalizaciji bolcsnika nakon uozivljcnog MU.
ncurosonographic mcihous, bascu on clinical analyscs anu
ncurocpiucmiological uaia.
4. Spccific prcvcniion anu ihcrapcuiic mcihous arc
proposcu in orucr io posiponc ihc ucvclopmcni of CVD
anu sirokc io ihc laicr phasc of human lifc in a spccific
communiiy.
5. Organizaiion of moucrn, scicniifically bascu ap-
proachcs io ihc managcmcni of 'hypcracuic sirokc`, un-
ucrsianuing ihc paihophysiology of ihis ccrcbrovascular
caiasirophc, c.g., using ihc bcsi possiblc, locally availablc
managcmcni possibiliiics of ihc 'ihcrapcuiic winuow`.
6. Organizc ihc bcsi, locally applicablc ucsign in ihc
siraicgics for ihc primary anu scconuary prcvcniion, carly
uiagnosis, bcsi possiblc managcmcni of sirokc as wcll as
in rchabiliiaiion anu rcsocializaiion of sirokc paiicnis.
16 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
Main 1opic !! !!. glavna icma
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IATIOIIYSIOIOGY OI ATI!ROSCI!ROSIS
IATOIIZIOIOGIJA AT!ROSKI!ROZ!
!van Karncr
Dcparimcni of Nuclcar Mcuicinc anu Iaihophysiology Univcrsiiy Hospiial, Osijck, Croaiia
Oujcl nuklcarnc mcuicinc paiofiziologijc, Klinicka bolnica Osijck, Osijck
Alihough many faciors arc involvcu in ihc gcncsis of
aihcrosclcrosis, hypcrcholcsicrolcmia, i.c. incrcascu LDL
conccniraiion in bloou is consiucrcu ihc major risk facior
for iis ucvclopmcni. Oihcr highly rclcvani risk faciors arc
hypcricnsion, iypc !! uiabcics mclliius, obcsiiy, cigarciic
smoking, inaucguaic physical aciiviiy, sircss, cic.
Nowauays, ihc proccss of aihcrosclcrosis is bclicvcu io
bc iniiiaicu by ihc aciivaiion or lcsion of cnuoihclial cclls,
whcrcby frcc oxygcn rauicals play a ccniral rolc. 1hc risk
faciors, cspccially hypcrcholcsicrolcmia anu aricrial hypcr-
icnsion, causc so-callcu oxiuaiivc sircss in cnuoihclial cclls.
!n paiicnis wiih iypc !! uiabcics mclliius, ihc samc cffcci
is cxcricu by siablc glycosylaicu proicin. Also, frcc oxygcn
rauicals arc iakcn uirccily inio ihc bouy wiih cigarciic
smokc.
Ircc oxygcn rauicals aci as mcsscngcr molcculcs anu
siimulaic ihc cxprcssion of auhcsion molcculcs by ihc iran-
scripiion sysicm aciivaiion. An imporiani iranscripiion
sysicm ihus aciivaicu is ihc NI-kB. 1hc occurrcncc of an
cvcr incrcasing numbcr of auhcsion molcculcs on cnuoi-
hclial ccll mcmbrancs lcaus io monocyic auhcrcncc io ihc
aricrial cnuoihclium, wiih simuliancous LDL pcnciraiion
ihrough ihc iniaci cnuoihclium. LDL arc ihcn oxiuizcu
in ihc subcnuoihclial spacc unucr ihc aciion of cnuoihc-
lial ccll lipopcroxiuasc anu frcc oxygcn rauicals formcu in
!ako u nasianku aicrosklcrozc suujclujc mnosivo cim-
bcnika, hipcrkolcsicrolcmija, ounosno poviscna konccn-
iracija LDL-a u krvi smaira sc najvaznijim cimbcnikom
rizika u njczinom nasianku. Osiali vazni cimbcnici su hi-
pcricnzija, sccrna bolcsi iipa !!., prciilosi, puscnjc, sma-
njcna ijclcsna akiivnosi, sircs i urugi. Danas sc smaira ua
proccs aicrosklcrozc zapocinjc akiiviranjcm ili osiccnjcm
cnuoiclnih sianica, pri ccmu slobouni rauikali kisika ima-
ju srcuisnju ulogu. Cimbcnici rizika, a poscbno hipcrko-
lcsicrolcmija i aricrijska hipcricnzija, u cnuoiclnim siani-
cama uzrokuju izv. oksiuaiivni sircs. U oboljclih ou iipa !!.
sccrnc bolcsii siabilno glikoziliranc bjclanccvinc ujcluju
na isii nacin. S cigarcinim uimom sc izravno u organizam
unosc slobouni rauikali kisika.
Slobouni rauikali kisika ujcluju kao vjcsnickc molckulc
i poiicu akiiviranjcm iranskripcijskih susiava izrazaj auhc-
zijskih molckula. Vazan iranskripcijski susiav koji sc akiivira
jc NI-kB.
Iojava svc vccga broja auhczijskih molckula na mcm-
branama cnuoiclnih sianica uovoui uo prijanjanja mono-
ciia uz cnuoicl aricrija uz isiouobni prouor LDL-a kroz in-
iakian cnuoicl ic sc isii u subcnuoiclnom prosioru oksiuira
pou ujclovanjcm lipopcroksiuazc cnuoiclnih sianica i slo-
bounih rauikala kisika nasialih u isiim sianicama, ali i slo-
bounih rauikala kisika iz makrofaga i glaikih misinih sia-
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 17
nica. Oksiuirani LDL ima urukcija svojsiva ou LDL-a. Ok-
siuirani LDL jc kcmoiaksican za monociic, ciioioksican jc
i imunogcn jc. Oksiuirani LDL u sianicc ulazi posrcusivom
poscbnih rcccpiora-cisiaca koji sc nalazc na mcmbranama
makrofaga. Oksiuirani LDL poiicc cnuoiclnc sianicc na
luccnjc kcmokina i ciiokina, a oni siimuliraju proccs scljc-
nja monociia u subcnuoiclni prosior i njihovu uifcrcnci-
jaciju u makrofagc. Zbog jakc kcmoiaksijc oksiuirani LDL
privlaci makrofagc u subcnuoiclnom prosioru. U makrof-
agc ulazc oksiuirani LDL-i posrcusivom rcccpiora-cisiaca.
Rcccpiori cisiaci ncmaju sposobnosi rcgulacijskoga sni-
zcnja, iako ua u makrofagc ulazi vclika kolicina oksiuiranih
LDL-a i oni sc na kraju prcivaraju u pjcnasic sianicc. Ula-
zak oksiuiranih LDL-a u makrofag akiivira makrofagc na
luccnjc mnogih akiivnih ivari kao sio su ciiokini: IDGI,
inicrlcukin 1, 1NI, iransformirajui cimbcnik rasia alfa i
bcia i ur. 1 limfociii koji sc nalazc privuccni u subcnuo-
iclni prosior lucc ciiokinc. Ciiokini poiicu cnuoiclnc siani-
cc ua na svojc mcmbranc izlucc auhczijskc molckulc kojc
pak omoguuju prijanjanjc svc vccga broja monociia uza
siijcnku krvnc zilc uz poiicanjc prolifcracijc glaikih mi-
sinih sianica mcuijc. !zrazcnim ciioioksicnim ucinkom
oksiuirani LDL osicujc cnuoicl krvnc zilc. Lnuoicl sc
mozc osiciiii i uslijcu mchanickoga ujclovanja poviscnoga
krvnoga ilaka, uuzcga ili opciovanoga spazma aricrija. U
iako osiccnom cnuoiclu smanjcna jc sinicza inhibiiora
agrcgacijc irombociia prosiaciklina (IG!2) uz isiouobno
povcanu siniczu pojacivaca agrcgacijc irombociia irom-
boksana (1xA2), a oba proccsa pogouuju nasianku mi-
kroiromba. !z irombociia sc oslobaoa irombociini cimbc-
nik rasia koji zajcuno s LDL-om i nckim hormonima (ponaj-
prijc inzulinom) poiicc puiovanjc glaikih misinih siani-
ca iz mcuijc u iniimu i njihovo umnazanjc na mjcsiu lczi-
jc. HDL koci iaj ucinak LDL-a i io jc jcuno ou njcgovih
proiuaicrosklcroiskih ujclovanja. 1rombociini cimbcnik
rasia osloboocn iz irombociia poiicc i siniczu rcccpiora
cisiaca u misinim sianicama, iako ua i onc poprimaju iz-
glcu pjcnasiih sianica. Ovaj poccini siauij porcmcaja kaua
lipiuc nalazimo prcicziio unuiar pjcnasiih sianica zovcmo
masnom prugom koja mozc i ncsiaii ako nisu osiccni mc-
hanizmi uklanjanja suvisnog kolcsicrola u sianicama. U
slucaju pak irajno poviscnih konccniracija LDL-a i ponav-
ljanog osiccnja proccs aicrosklcrozc naprcuujc, pri ccmu
pjcnasic sianicc propauaju, iz njih sc oslobaoaju ivari kojc
poiicu umnazanjc glaikih misinih sianica i fibroblasia.
Dolazi uo oksiuacijc lipiua u makrofagima u ioksicnc
rauikalc (prcvlauavaju pcroksiui) koji razarajui okolnc
sianicc priuonosc sircnju aicrosklcroiskog osiccnja. Zbog
nakupljanja svc vcc kolicinc kolcsicrola iz LDL-a siimu-
lira sc sinicza kolagcna, clasiina i mukopolisahariua u glai-
kim misinim sianicama ic njihovo pojacano oulaganjc ivori
ihcsc cclls as wcll as of frcc oxygcn rauicals from ihc mac-
rophagcs anu smooih musclc cclls. 1hc oxiuizcu LDL havc
uiffcrcni propcriics ihan LDL. Oxiuizcu LDL arc chcmo-
iaxic for monocyics, cyioioxic, anu immunogcnic. Oxi-
uizcu LDL cnicr ihc cclls c/c spccial scavcngcr rcccpiors
locaicu on macrophagc mcmbrancs. Oxiuizcu LDL siim-
ulaic cnuoihclial cclls io sccrcic chcmokincs anu cyiok-
incs, which in iurn siimulaic ihc proccss of monocyic mi-
graiion io ihc subcnuoihclial spacc anu ihcir uiffcrcniia-
iion io macrophagcs. Bccausc of sirong chcmoiaxis, ihc
oxiuizcu LDL aiiraci macrophagcs in ihc subcnuoihclial
spacc. Oxiuizcu LDL cnicr ihc macrophagcs c/c scavcn-
gcr rcccpiors. 1hcsc scavcnging rcccpiors posscss no
uown-rcgulaiion abiliiy, ihus a largc amouni of oxiuizcu
LDL cnicr ihc macrophagcs, anu ihcy cvcniually irans-
form inio foam cclls. 1hc cniry of oxiuizcu LDL siimu-
laics ihc macrophagcs io sccrcic a numbcr of aciivc sub-
sianccs such as cyiokincs, IDGI, inicrlcukin 1, 1NI, alfa
anu bcia iransforming growih faciors, cic. 1 lymphocyics,
bcing aiiracicu io ihc subcnuoihclial spacc, rclcasc cyiok-
incs. Cyiokincs siimulaic cnuoihclial cclls io sccrcic au-
hcsion molcculcs on ihcir mcmbrancs, which in iurn cn-
ablc auhcsion of an cvcr growing numbcr of monocyics io
ihc vascular wall, anu siimulaic prolifcraiion of ihc mcuia
smooih musclc cclls. Oxiuizcu LDL uamagc ihc bloou
vcsscl cnuoihclium by ihcir pronounccu cyioioxic cffcci.
Lnuoihclial lcsion may also bc inuuccu by ihc mcchani-
cal aciion of clcvaicu bloou prcssurc or rccurrcni aricrial
spasm. !n ihc cnuoihclium ihus uamagcu, ihc synihcsis
of ihc plaiclci aggrcgaiion inhibiior prosiacyclin (IG!2)
is uiminishcu, wiih simuliancously incrcascu synihcsis of
ihc plaiclci aggrcgaiion siimulaior ihromboxanc (1xA2);
boih of ihcsc proccsscs favor ihc occurrcncc of micro-
ihrombi. 1hc plaiclci growih facior is rclcascu from ihc
plaiclcis anu siimulaics, along wiih LDL anu somc hor-
moncs (primarily insulin), ihc smooih musclc ccll migra-
iion from ihc mcuia io ihc iniima, anu ihcir prolifcraiion
ai ihc siic of lcsion. 1his cffcci of LDL is inhibiicu by
HDL, anu ii is onc of ihc HDL aniiaihcrosclcroiic aciions.
1hc plaiclci growih facior rclcascu from ihc plaiclcis also
siimulaics ihc synihcsis of scavcngcr rcccpiors in smooih
musclc cclls, so ihai ihcy assumc a foam ccll appcarancc.
1his iniiial siagc of ihc uisorucr, whcn lipius arc mosily
founu wiihin ihc foam cclls, is callcu faiiy sircak ihai may
uisappcar unlcss ihc mcchanisms of cxccss ccllular cho-
lcsicrol climinaiion arc impaircu. !n casc of pcrmancnily
clcvaicu LDL conccniraiions anu rccurrcni lcsions, ihc
aihcrosclcroiic proccss will progrcss, whcrcby foam cclls
uisinicgraic, ihcrcby rclcasing ihc subsianccs ihai siim-
ulaic smooih musclc ccll anu fibroblasi prolifcraiion. 1hc
lipius in ihc macrophagcs unucrgo oxiuaiion io ioxic rau-
18 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
icals (pcroxiucs prcvail), which ucsiroy ihc surrounuing
cclls anu ihus coniribuic io propagaiion of ihc aihcrosclc-
roiic lcsion. 1hc accumulaiion of cvcr morc cholcsicrol
from LDL siimulaics ihc synihcsis of collagcn, clasiin anu
mucopolysacchariucs in smooih musclc cclls, anu ihcir
cnhanccu ucposiiion lcaus io ihc formaiion of aihcroma.
1hc aihcroma lcaus io iniimal ihickcning ai ihc siic of
cnuoihclial lcsion, ihus mouifying ihc bloou flow anu caus-
ing furihcr cnuoihclial uamagc anu lcsion propagaiion.
Aihcrosclcrosis narrows ihc lumcn of ihc vcsscl, lcauing
io iissuc hypoxia. 1hc loss of vascular clasiiciiy lcaus io
bloou prcssurc clcvaiion, incrcasing ihc risk of vascular wall
rupiurc anu hcmorrhagc inio ihc iissuc.
ATI!ROSCI!ROSIS A^! IÎIAMMATIO^
AT!ROSKI!ROZA I \IAIA
Zlaiko 1rkanjcc
Aihcrosclcrosis unucrlics a majoriiy of sirokc cascs.
Aihcrosclcrosis has classically bccn ucscribcu as a progrcs-
sivc uiscasc characicrizcu by ihc ucposiiion of lipius, fi-
brous maicrial anu calcium in ihc aricrial wall. Rcccni
conccpis poini io ihc ccniral rolc of inflammaiory proccss
in ihc ucvclopmcni of boih aihcroma anu ihrombus on ihc
aihcroma. !nflammaiory proccss is prcscni in ihc carlicsi
as wcll as auvanccu aihcrosclcroiic lcsions. Bcsiucs ihc
aciion of oihcr known risk faciors for ihc onsci anu pro-
grcssion of aihcrosclcrosis, ii is cvcr morc cviucni ihai
inflammaiion plays a major rolc in aihcrogcncsis.
!n ihc vcry bcginning of aihcrogcncsis, ihc iniiial lc-
sion of ihc aricrial cnuoihclium occurs. 1hc cnuoihclial
lcsion may bc causcu by ihc inflammaiory proccss. 1hc
cnuoihclial cclls involvcu by ihc lcsion havc a uiminishcu
vasouilaiaiory funciion, anu an array of proinflammaiory
funciions arc aciivaicu on ihc uamagcu cnuoihclium, such
as cxprcssion of auhcsion molcculcs (VCAM anu !CAM)
on ihc cnuoluminal wall of ihc cnuoihclium, anu cyiok-
inc anu complcmcni rclcasc, causing monocyic auhcsion
aicrom. Aicrom uzrokujc zaucbljanjc iniimc na mjcsiu
osiccnja cnuoicla, cimc sc iijck krvi mijcnja, sio pak uz-
rokujc ualjnja osiccnja cnuoicla i sircnjc lczijc. Aicrosklc-
roza suzava promjcr zilc, sio voui ka ikivnoj hipoksiji. Gu-
biiak clasiiciicia krvnc cilc uovoui uo povcanja krvnoga
ilaka, cimc sc povcava rizik ou puknua siijcnkc i krvarc-
nja u ikivo.
U poulozi vcinc mozuanih uuara nalazi sc aicrosklc-
roza. Aicrosklcroza sc klasicno opisivala kao progrcsivna
bolcsi obiljczcna nakupljanjcm lipiua, fibroznog maicrija-
la i kalcija u siijcnci aricrija. Novijc spoznajc ukazuju na
srcuisnjc znaccnjc upalnog proccsa kako u nasianku aic-
roma iako i u nasianku iromba na aicromu. Upalni proccs
prisuian jc u najranijim aicrosklcroiskim lczijama kao i u
uznaprcuovalim lczijama. Uz ujclovanjc osialih poznaiih
cimbcnika rizika za nasianak i progrcsiju aicrosklcrozc
posiajc svc jasnijc ua upala igra vrlo znacajna ulogu u aic-
rogcnczi.
U samom pocciku aicrogcnczc uolazi uo poccinog
osiccnja cnuoicla aricrija. Moguc jc ua upalni proccs
uzrokujc osiccnjc cnuoicla. Osiccnc sianicc cnuoicla
imaju smanjcnu vazouilaiacijsku funkciju, a na osiccnom
cnuoiclu akiivira sc cijcli spckiar proupalnih funkcija:
uolazi uo cksprcsijc auhczijskih molckula (VCAM i !CAM)
na cnuoluminalnoj siijcnci cnuoicla, oslobaoaju sc ciioki-
ni i komplcmcni, sio uzrokujc auhcziju monociia na lczi-
ju i ulazak monociia u subcnuoiclni prosior kroz osiccni
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 19
cnuoicl. U subcnuoiclnom prosioru nasiavlja sc upalni
proccs koji jc ougovoran za najznacajnijc uogaoajc u aicro-
gcnczi: oksiuaciju LDL ccsiica, rcgruiiranjc monociia i
iransformaciju u makrofagc, nasianak pjcnusavih sianica i
ucpoziia lipiua, akiiviranjc irombociia, migraciju i proli-
fcraciju glaikih misinih sianica, siniczu cksiracclularnog
mairiksa i vczivnog ikiva. Uz onu u nasianku ranih aicro-
sklcroiskih lczija, upala ima znacajnu ulogu i u progrcsiji
aicrosklcroiskih lczija. !zglcua ua jc najznacajniji cimbc-
nik koji uovoui uo progrcsijc rupiura kapc plaka i izlaganjc
saurzaja plaka krvnoj siruji, sio uovoui uo nasianka irom-
ba na plaku. U nasianku rupiurc plaka, posljcuicnc pro-
grcsijc plaka i pojavljivanju klinicki znacajnih iromboiskih
komplikacija vrlo jc vazna graoa plaka. Mcki plakovi imaju
vcliku lipiunu jczgru, mnosivo upalnih sianica (prcicziio
makrofaga i 1 limfociia), rijcikc glaikc misinc sianicc i
ianku kapu graocnu ou fragmcniiranog kolagcna. 1vrui, fi-
brozni plakovi imaju malu lipiunu jczgru, rijcikc upalnc
sianicc, mnosivo glaikih misinih sianica i ucbclu kapu
graocnu ou kolagcna iipa !. i !!!., clasiina i proicoglikana
kojc siniciiziraju glaikc misinc sianicc. Mcki plakovi
mnogo su skloniji rupiuri ou fibroznih. 1ijckom upalnog
proccsa oslobaoaju sc cnzimi mijclopcroksiuazc, clasioli-
iicki kaicpsini i mcialoproicazc kojc razgraouju makro-
molckulc kapc plaka, sio uzrokujc slabljcnjc sirukiurc kapc
plaka. Uz io 1 limfociii proizvouc gama inicrfcron koji
znacajno smanjujc siniczu kolagcna. Oba proccsa mogu
uovcsii uo rupiurc plaka, nasianka iromba na rupiurira-
nom plaku i posljcuicnih klinickih komplikacija. Viuljivo
jc ua upalni proccs ima znacajnu ulogu kako u nasianku
iako i u progrcsiji aicrosklcroiskih lczija. Upalni proccs
mozc biii sicrilan, a ou moguih uzrocnika spominju sc
C//coyd/c pr-eoor/c-, H-oop/y/es /r//e-rcc-, Myop/csoc
pr-eoor/c-, H-//o/ct-r py/or/, /too-c/oc/res, /-rp-s s/op/-x
c/res, Epst-/r-Bcrroc c/res. Ovi mikroorganizmi naocni su
u raznim aicrosklcroiskim lczijama, kao i u bolcsnika s kli-
nickim komplikacijama aicrosklcrozc (infarki miokarua,
mozuani uuar), sio govori u prilog ulogc navcucnih paio-
gcna u nasianku upalc koja mozc uovcsii uo nasianka i pro-
grcsijc aicrosklcroiskih lczija. !spiiujc sc ujclovanjc anii-
bioiika, uglavnom makroliua, u prcvcnciji nasianka i pro-
grcsijc aicrosklcroiskih lczija, no zasaua nisu objavljcni rc-
zuliaii koji bi poivruili ujcloivornosi primjcnc aniibioiika
u prcvcnciji aicrosklcrozc.
io ihc lcsion anu monocyic migraiion io ihc subcnuoihc-
lial spacc ihrough uamagcu cnuoihclium. !n ihc subcnuoi-
hclial spacc, ihc inflammaiory proccss coniinucs, ihus
bcing rcsponsiblc for ihc mosi significani cvcnis in aih-
crosclcrosis, i.c. oxiuaiion of LDL pariiclcs; monocyic rc-
cruiimcni anu iransformaiion io macrophagcs; formaiion
of foam cclls anu lipiu ucposiis; plaiclci aciivaiion; smooih
musclc ccll migraiion anu prolifcraiion; anu synihcsis of
cxiraccllular mairix anu conncciivc iissuc.
!n auuiiion io ihc gcncsis of aihcrosclcroiic lcsions,
inflammaiion has a significani rolc also in ihc progrcssion
of ihcsc lcsions. !i appcars ihai rupiurc of ihc plaguc cap
anu rclcasc of ihc plaguc conicni inio ihc circulaiion is ihc
mosi imporiani facior ihai lcaus io ihc progrcssion of aih-
crosclcrosis. Ilaguc composiiion is of uimosi imporiancc
for ihc occurrcncc of plaguc rupiurc, conscgucniial plaguc
progrcssion, anu ucvclopmcni of clinically significani
ihrombolyiic complicaiions. Sofi plagucs havc largc lipiu
nuclci, abunuancc of inflammaiory cclls (mosily macroph-
agcs anu 1 lymphocyics), rarc smooih musclc cclls, anu
ihin cap composcu of fragmcnicu collagcn. Soliu, fibrous
plagucs havc small lipiu nuclci, rarc inflammaiory cclls,
abunuani smooih musclc cclls, anu ihick cap composcu
of iypc ! anu !!! collagcn, clasiin anu proicoglycans syn-
ihcsizcu by smooih musclc cclls. Sofi plagucs arc much
morc susccpiiblc io rupiurc ihan fibrous plagucs. During
ihc inflammaiory proccss, ihc cnzymc myclopcroxiuasc,
clasiolyiic caihcpsins anu mcialloproicascs arc bcing rc-
lcascu, lcauing io uccomposiiion anu siruciural wcakcn-
ing of ihc plaguc cap. !n auuiiion, 1 lymphocyics prouucc
gamma inicrfcron, which significanily rcuuccs ihc synihc-
sis of collagcn. Boih of ihcsc proccsscs can rcsuli in plaguc
rupiurc, ihrombus formaiion on ihc rupipurcu plaguc, anu
conscgucniial clinical complicaiions.
1hus, ii is obvious ihai inflammaiory proccss plays a
major rolc in boih ihc occurrcncc anu progrcssion of aih-
crosclcroiic lcsions. !nflammaiory proccss can bc 'sicrilc`,
wiih C//coyd/c pr-eoor/c-, Hc-oop/y/es /r//e-rcc-, Myop/cs-
oc pr-eoor/c-, H-//o/ct-r py/or/, ytoo-c/oc/res, /-rp-s s/o-
p/-x c/res, crd Epst-/r-Bcrr c/res rcporicu as canuiuaic
agcnis. 1hcsc microorganisms havc bccn founu in various
aihcrosclcroiic lcsions as wcll as in paiicnis wiih clinical
complicaiions of aihcrosclcrosis (myocaruial infarciion,
sirokc), supporiing ihc rolc of ihcsc paihogcns in ihc gcn-
csis of inflammaiion ihai can lcau io ihc onsci anu pro-
grcssion of aihcrosclcroiic lcsions. 1hc aciion of aniibioi-
ics, mosily macroliucs, in ihc prcvcniion of onsci anu pro-
grcssion of aihcrosclcroiic lcsions has bccn invcsiigaicu,
howcvcr, no rcsulis confirming ihc cfficacy of aniibioiics
in ihc prcvcniion of aihcrosclcrosis havc bccn rcporicu io
uaic.
20 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
ART!RIAI IYI!RT!^SIO^ A^! ATRIAI IIHRIIIATIO^ -
RISK IACTORS IOR STROK!
ART!RIJSKA III!RT!^ZIJA I ATRIJSKA IIHRIIACIJA:
CIMH!ÎCI RIZIKA MOZ!AÔG \!ARA
Kaiija Caiipovi-Vcsclica, Blanka Glavas-Konja
Dcparimcni of Mcuicinc, Osijck Univcrsiiy Hospiial, Osijck, Croaiia
!nicrna klinika, Klinicka bolnica Osijck, Osijck
Karuiovaskularna bolcsi jc najccsi uzrok smrii u ra-
zvijcnim zcmljama mcou ouraslima siarim 30 ili visc go-
uina. Koronarna bolcsi jc glavni krivac nakon kojcga slijcui
mozuani uuar. Anaiomska i paioloska osnova ovih cniiicia
jc aicrosklcroza. U Hrvaiskoj jc karuiovaskularna bolcsi
uzrok smrii u 537 slucajcva, pokazujc ircnu porasia i pomi-
canjc prcma mlaooj uobnoj skupini. Hipcricnzija jc glavni
cimbcnik rizka za mozuani infarki i inirakranijsko krvarcnjc
na koji jc moguc uijccaii. !nciucncija mozuanog uuara
rasic proporcionalno sa sisiolickim i uijasiolickim krvnim
ilakom. Krvni ilak, narociio sisiolicki, rasic s uobi. !zolira-
na sisiolicka hipcricnzija (sisiolicki krvni ilak >160 mm
Hg, a uijasiolicki <90 mm Hg) jc vazan cimbcnik rizika
mozuanog uuara u siarih osoba. !nicnzivna konirola krvnog
ilaka (RR <140/90, uijabciicari RR <130/80) smanjila jc
morbiuiici i morialiici ou mozuanog uuara za 407. Siuuijc
HOIL i IROGRLSS pokazalc su prcvcnciju mozuanog
uuara vcu ncgo sio sc occkujc snizcnjcm krvnog ilaka.
Usprkos naporu u cuukaciji, znacajan posioiak populacijc
ima ncuijagnosiiciranu ili losc lijcccnu hipcricnziju. Irc-
poruka jc rcuovno mjcrcnjc krvnog ilaka u ouraslih, najma-
njc svakc uvijc gouinc, i inicnzivno lijcccnjc prcma prc-
porukama. Airijska fibrilacija jc ccsia ariimija i vazan cim-
bcnik rizika mozuanog uuara. Gouisnji rizik mozuanog
Caruiovascular uiscasc is ihc lcauing causc of ucaih in
auulis agcu 30 ycars in inuusirializcu counirics. Coronary
uiscasc is ihc major 'culprii`, followcu by sirokc. Aihcro-
sclcrosis unucrlics ihc anaiomic anu paihologic back-
grounu of ihcsc cniiiics. !n Croaiia, caruiovascular uiscasc
is ihc causc of ucaih in 537 of cascs, showing an incrcas-
ing icnucncy anu shifi iowarus youngcr agc groups.
Hypcricnsion is ihc major mouifiablc risk facior for
sirokc anu iniracranial hcmorrhagc. 1hc inciucncc of
sirokc riscs proporiionally wiih sysiolic anu uiasiolic bloou
prcssurc. Bloou prcssurc, cspccially sysiolic bloou prcssurc,
riscs wiih agc. !solaicu sysiolic hypcricnsion (sysiolic bloou
prcssurc >160 mm Hg, anu uiasiolic bloou prcssurc <90
mm Hg) is an imporiani risk facior for sirokc in ihc clucr-
ly. !nicnsivc bloou prcssurc conirol (BI <140/90, anu
<130/80 in uiabciics) has rcuuccu sirokc morbiuiiy anu
morialiiy by 407. 1hc HOIL anu IROGRLSS siuuics
havc shown ihc prcvcniion of sirokc io cxcccu ihc onc
cxpccicu from bloou prcssurc rcuuciion alonc. !n spiic of
cuucaiion, a high proporiion of ihc populaiion havc non-
uiagnoscu or poorly ircaicu hypcricnsion. 1hc rccommcn-
uaiions incluuc rcgular bloou prcssurc mcasurcmcni in
auulis, i.c. ai lcasi cvcry iwo ycars, anu inicnsivc ircaimcni
in linc wiih ihc rccommcnuaiions.
1. 1RKAN]LC Z, DLMAR!N V. Aihcrosclcrosis anu inflammaiion.
Acia Clin Croai 1999;38 (Suppl 1):22-3.
2. L!BBY I, R!DKLR IM, MASLR! A. !nflammaiion anu aihcrosclc-
rosis. Circulaiion 2002;105:1135-43.
3. ROBB!L L, L!BBY I. !nflammaiion anu aihcroihrombosis. Ann N
Y Acau Sci 2001;947:167-80.
4. ROSS R. Aihcrosclcrosis: an inflammaiory uiscasc. N Lngl ] Mcu
1999;340:115-26
5. SUG!YAMA S, OKADA Y, SUKHOVA GK, -t c/. Macrophagc myclop-
croxiuasc rcgulaiion by granulocyic macrophagc colony-siimulaiing
facior in human aihcrosclcrosis anu implicaiions in acuic coronary
synuromcs. Am ] Iaihol 2001;158:879-91.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 21
uuara u bolcsnika s ncvalvularnom fibrilacijom airija jc 37
uo 57. Airijska fibrilacija ougovorna jc za 157-207 ccrc-
brovaskularnih uogaoaja ishcmijskog uzroka. Cimbcnici
rizika mozuanog uuara su prcboljcli mozuani uuari ili iran-
ziioma ishcmijska aiaka (1!A) u anamnczi, hipcricnzija i
hipcricnzija u anamnczi, smanjcna funkcija lijcvog vcn-
irikula, karuiomcgalija, hipcrirofija lijcvog vcnirikula, ui-
jabcics, uvcan lijcvi airij >50 mm, iransczofagcalni
chokaruiografski nalaz iromba u lijcvom airiju, uob i koro-
narna bolcsi. Dugoirajna oralna aniikoagulanina icrapija
rizicnih bolcsnika s airijskom fibrilacijom smanjila jc rizik
mozuanog uuara za 687. Mcouiim, aniikoagulanina icra-
pija sc slabo primjcnjujc i losc voui u rizicnih bolcsnika s
airijskom fibrilacijom. Sira i priklaunija upoircba kombi-
nacijc aspirina i varfarina smanjiii c inciucnciju mozuanog
uuara u siarih osoba.
Airial fibrillaiion is a common arrhyihmia anu an im-
poriani risk facior for sirokc. !n paiicnis wiih nonvalvular
airial fibrillaiion, ihc annual risk of sirokc is 37 - 57. Airi-
al fibrillaiion is rcsponsiblc for 157 - 207 of ischcmic sirokc
cascs. 1hc risk faciors for sirokc in paiicnis wiih airial fi-
brillaiion incluuc a hisiory of sirokc or iransicni ischcmic
aiiack, hypcricnsion, hisiory of hypcricnsion, ucprcsscu
lcfi vcniricular funciion, caruiomcgaly, lcfi vcniricular
hypcrirophy, uiabcics mclliius, lcfi airial cnlargcmcni >50
mm, iranscsophagcal cchocaruiography finuing of a ihrom-
bus in ihc lcfi airium, agc, anu coronary uiscasc. Longicrm
oral aniicoagulani ihcrapy rcuuccu ihc risk of sirokc by
687 in risk paiicnis wiih airial fibrillaiion. Howcvcr, anii-
coagulani ihcrapy has gcncrally bccn inaucguaicly prc-
scribcu anu poorly conuucicu in paiicnis wiih airial fibril-
laiion. 1hc inciucncc of sirokc in ihc clucrly can bc rc-
uuccu by a wiucr anu morc appropriaic usc of a combina-
iion of aspirin anu warfarin.
STROK! I^ !IAH!TIC IATI!^TS
MOZ!AÎ \!AR \ OSOHA SA S!C!RÔM HOI!SC\
Anic !vanui
Noi rcccivcu
Nijc primljcno
CIGAR!TT! SMOKI^G AS A RISK IACTOR IOR STROK!
I\S!^J! KAO CIMH!ÎK RIZIKA ZA MOZ!AÎ \!AR
Ncvcnka Cop-Blazi
Mcou brojnim rizicnim cimbcnicima ougovornim za
razvoj i nasianak mozuanog uuara puscnjc sc isiicc kao cim-
bcnik koji isiouobno na razliciic nacinc ugrozava funkcion-
Among numcrous risk faciors ihai arc rcsponsiblc for
ihc onsci anu ucvclopmcni of sirokc, cigarciic smoking
is cmphasizcu as a facior ihai simuliancously affccis ihc
22 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
iranjc cirkulacijskog susiava. Akiivnim i pasivnim pusc-
njcm u iijclo sc unosi nckoliko iisua kcmijskih sasiojaka.
Irovcucno jc niz isirazivanja o mchanizmima ujclovanja
pojcuinih komponcnaia uuhanskog uima na vaskularni
susiav i urugc organskc susiavc u iijclu, uok sc o njihovim
mcousobnim inicrakcijama, kao i inicrfcriranju s uzima-
njcm razliciiih lijckova jos uvijck ncuovoljno zna.
Kou pusaca jc naocno ua ovisno o kolicini popuscnih
cigarcia imaju znacajno visu razinu ukupnog kolcsicrola,
irigliccriua, lipoproicina vrlo niskc gusioc (VLDL), lipo-
proicina niskc gusioc (LDL) ic nizu razinu lipoproicina
visokc gusioc (HDL) i apolipoproicina A 1, koji imaju an-
gioproickiivno ujclovanjc. Zbog porcmccnc lipolizc kou
pusaca nakon sio su konzumirali masni obrok nc uolazi uo
poviscnja HDL-a, sio sc normalno uocava kou ncpusaca.
Ova sc pojava objasnjava iimc sio nikoiin poiicc oslobaoa-
njc aurcnalina, povcava sc konccniracija slobounih mas-
nih kisclina (IIA) kojc poiicu jcircno luccnjc VLDL-a.
Konccniracija HDL-a sc mijcnja obrnuio s konccniracijom
VLDL-a. Uz io, kou pusaca jc zabiljczcna i poviscna kon-
ccniracija iromboksana A 2 ic povcana rcakiivnosi irom-
bociia. Iusaci iakoocr imaju poviscnu razinu fakiora V!!. i
fibrinogcna. Oslobaoanjc prosiaciklina i fakiora LDR koji
rcguliraju bazalni ionus krvnih zila iakoocr jc kou uugo-
gouisnjih pusaca porcmccno. Iosiojc isirazivanja koja
upuuju na mogunosi osiccnja cnuoiclnih sianica ugljik
monoksiuom sio ga saurzi uuhanski uim, zbog ccga sc po-
vcava propusnosi siijcnkc i omoguujc vcc infiliriranjc
lipiua. Uz navcucnc mchanizmc ujclovanja puscnjc izazi-
va i niz urugih proccsa koji uoprinosc aicrogcnczi. Spcci-
ficnosi puscnja jc u iomc sio pusaci hcicrogcnu smjcsu s
prcko cciiri iisuc razliciiih kcmijskih spojcva najccsc
unosc u iijclo uvaucsciak i visc puia na uan, i io kroz uugo
razuobljc. Opciovana simpaiicka siimulacija i vazokon-
sirikcijsko ujclovanjc nikoiina, uza smanjcnu razinu kisi-
ka u krvi, s obzirom na io ua jc uio hcmoglobina prcivorcn
u fizioloski ncakiivan karboksihcmoglobin, znacajno uopri-
nosc aicrogcnczi. S farmakoloskog siajalisia, nikoiin, po
svom kcmijskom sasiavu alkaloiu, sasiojak jc uuhanskog
uima s najsnaznijim ujclovanjcm. Nikoiin jc, uz io sio
ugrozava funkcioniranjc cirkulacijskog susiava, izraziio
auikiivan i smaira sc ougovornim za razvoj mciabolicnc
ovisnosii.
Rczuliaii cpiucmioloskih isirazivanja upuuju na io ua
mali posioiak mlauih koji pocnu pusiii, ick oko pci posio,
osiajc na nckoliko cigarcia na uan, uok sc kou osialih po-
siupno razvija iolcrancija i posiaju ovisni. Uzimajui u obzir
cinjcnicu ua jc puscnjc panucmijski prosircno, ua broj
pusaca unaioc svim uokazima o sicinosii puscnja za zurav-
ljc u mnogim zcmljama i ualjc rasic, narociio mcou mlaui-
ma, mozc sc u buuunosii, ako sc ovaj ircnu nc promijcni,
circulaiory sysicm funciion in a numbcr of ways. By ciihcr
aciivc or passivc cigarciic smoking, scvcral ihousanus of
various chcmical subsianccs arc iakcn io ihc bouy. Many
siuuics havc invcsiigaicu ihc mcchanisms of aciion of
pariicular iobacco smokc componcnis on ihc vascular sys-
icm anu oihcr organ sysicms in ihc bouy, whcrcas ihcir
inicraciions as wcll as inicrfcrcnccs wiih various urugs siill
rcmain pariially obscurc.
Dcpcnuing on ihc numbcr of cigarciics, smokcrs havc
bccn founu io havc significanily highcr lcvcls of ioial cho-
lcsicrol, iriglyccriucs, vcry low ucnsiiy lipoproicin (VLDL)
anu low ucnsiiy lipoproicin (LDL), anu lowcr lcvcls of high
ucnsiiy lipoproicin (HDL) anu apolipoproicin A1, known
for ihcir angioproicciivc aciion. !n smokcrs, uuc io im-
paircu lipolysis, ihc iniakc of faiiy mcal is noi followcu by
a HDL incrcasc, which is normally obscrvcu in nonsmok-
crs. 1his phcnomcnon has bccn cxplaincu by ihc faci ihai
nicoiinc siimulaics ihc rclcasc of aurcnalinc, followcu by
an incrcasc in ihc conccniraiion of frcc faiiy acius (IIA),
which siimulaic hcpaiic sccrciion of VLDL. 1hc conccn-
iraiion of HDL changcs invcrscly io ihc conccniraiion of
VLDL. !n auuiiion, an clcvaicu conccniraiion of ihrom-
boxanc A2 anu incrcascu plaiclci rcaciiviiy havc bccn rc-
corucu in smokcrs. Smokcrs also havc clcvaicu lcvcls of
facior V!! anu fibrinogcn. 1hc rclcasc of prosiacyclinc anu
LDR facior, which rcgulaic basal vascular ionus, is also
impaircu in longicrm smokcrs. Somc siuuics havc suggcsi-
cu ihc possiblc cnuoihclial ccll uamagc by carbon monox-
iuc coniaincu in iobacco smokc, ihus incrcasing ihc vas-
cular wall pcrmcabiliiy anu cnabling massivc lipiu infilira-
iion. !n auuiiion io ihcsc mcchanisms of aciion, cigarciic
smoking inuuccs a numbcr of oihcr proccsscs ihai conirib-
uic io aihcrogcncsis.
1hc spccific fcaiurc of cigarciic smoking is ihai a hc-
icrogcncous mixiurc of morc ihan 4000 uiffcrcni chcmi-
cal compounus arc usually iakcn io ihc bouy on 20 or morc
occasions uaily ovcr a long pcriou of iimc. 1hc rcpciiiivc
sympaihciic siimulaiion anu vasoconsiriciivc aciion of
nicoiinc, along wiih a uccrcascu bloou oxygcn lcvcl, bc-
causc hcmoglobin has bccn in pari iransformcu io ihc
physiologically inaciivc carboxyhcmoglobin, coniribuic
significanily io ihc ucvclopmcni of aihcrogcncsis.
Irom ihc pharmacological poini of vicw, nicoiinc, an
alkaloiu by iis chcmical composiiion, is a iobacco consii-
iucni wiih ihc mosi poicni aciion. !n auuiiion io aggra-
vaiing ihc circulaiory sysicm funciion, nicoiinc is cxircmc-
ly auuiciivc anu is consiucrcu rcsponsiblc for ihc ucvclop-
mcni of mciabolic ucpcnucncc. Rcsulis of cpiucmiologic
siuuics suggcsi ihai a small pcrccniagc, noi morc ihan 57,
of young pcoplc who siari smoking rcmain on only scvcral
cigarciics a uay, whcrcas all oihcrs grauually ucvclop iol-
crancc anu bccomc ucpcnucni.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 23
occkivaii jos visc malignih i cirkulacijskih bolcsii kojc su
izravno vczanc uz puscnjc uuhana. Rclaiivan rizik ou nas-
ianka subarahnoiunc hcmoragijc kou muskaraca, uugogo-
uisnjih icskih pusaca (oni koji pusc visc ou uvaucsci ciga-
rcia na uan) i zcna pusacica jc 7,3 u usporcubi s muskarci-
ma koji nisu nikaua pusili i zcnama ncpusacicama. Rizik
ou ishcmijskog mozuanog uuara jc kou icskih pusaca 2,7,
a kou pusaca koji pusc manjc ou uvaucsci cigarcia na uan
2,2 u ounosu na ncpusacc. Ircsiankom puscnja iaj sc rizik
smanjujc. Na razini svijcia racuna sc ua svakih ucsci sckun-
ua nciko umirc kao zriva puscnja. Mozuani uuar sc nalazi
visoko na ljcsivici morialiicia i morbiuiicia kako u razvijc-
nim zcmljama iako i u Hrvaiskoj. Iuscnjc jc u Hrvaiskoj
jos uvijck, nazalosi, jcuan ou najvcih javno zuravsivcnih
problcma s obzirom na vclik broj pusaca, poglaviio mcou
zcnama i mcou mlauima. Za occkivaii jc ua akiivnosii na
pourucju prcvcncijc puscnja i lijcccnja pusaca uoprincsu i
smanjcnju pojavnosii mozuanog uuara. Rizik puscnja sc u
javnosii jos uvijck poucjcnjujc. Djcca i mlaui su ccsio iz-
lozcni ncizravnim i izravnim priiiscima ua zapalc cigarc-
iu. Iasivno ili prisilno puscnjc jc jos uvijck vclik problcm
unaioc poziiivnim zakonskim propisima koji bi ircbali
pomoi ua sio visc prosiora buuc osloboocno uuhanskog
uima. Iusaci su najccsc viscsiruki bolcsnici. Ccsc obo-
lijcvaju ou kronicnih bolcsii kojc zahiijcvaju uugoirajno
lijcccnjc, ccsc boravc u bolnici, izosiaju s posla, posiaju
invaliui i prijc vrcmcna umiru. Nc posioji zurava razina
puscnja uuhana.
Ircsianak puscnja, s urugc siranc, uonosi niz prcunos-
ii - ijclcsnih, cmocionalnih, urusivcnih i gospouarskih.
Mcou prcunosiima prcsianka puscnja smanjcnjc rizika
nasianka mozuanog uuara jc svakako jcuna ou vrlo znacaj-
nih prcunosii, s obzirom na io ua jcuna ircina oboljclih
ou mozuanog uuara umirc, ircina osiajc zivjcii s manjom
ili vcom invaliunosu, a samo ircina sc oporavlja.
Consiucring ihc faci ihai cigarciic smoking shows a
panucmic sprcau all ovcr ihc worlu, anu ihai ihc numbcr
of smokcrs siill is on an incrcasc in many counirics, cspc-
cially among ihc young, in spiic of all cviucncc for ihc uc-
irimcnial cffccis of cigarciic smoking, an cvcr rising raic
of malignani anu circulaiion uiscascs ihai arc uirccily as-
sociaicu wiih iobacco smoking shoulu bc cxpccicu in ihc
fuiurc, may ihis unfavorablc ircnu fail io changc.
1hc rclaiivc risk of subarachnoiu hcmorrhagc in mcn,
longicrm hcavy smokcrs (ihosc smoking >20 cigarciics a
uay), anu in womcn smokcrs is 7.3 as comparcu wiih ihc
mcn anu womcn who havc ncvcr smokcu cigarciics. 1hc
risk of ischcmic sirokc is 2.7 in hcavy smokcrs anu 2.2 in
ihosc smoking <20 cigarciics a uay, as comparcu wiih
nonsmokcrs. 1hc risk uccrcascs wiih guiiiing cigarciic
smoking.
!n ihc worlu, ii is csiimaicu ihai cvcry icn scconus onc
pcrson uics from smoking. Sirokc occupics a high placc on
ihc scalc of morbiuiiy anu morialiiy in boih inuusirializcu
counirics anu Croaiia. !n Croaiia, unforiunaicly, smoking
is siill onc of ihc major public hcalih problcms consiucr-
ing ihc high proporiion of smokcrs, cspccially among wom-
cn anu young populaiion. 1hc aciiviiics iakcn in ihc ficlu
of smoking prcvcniion anu ircaimcni of smokcrs arc also
cxpccicu io coniribuic io ihc rcuuciion of ihc prcvalcncc
of sirokc. 1hc risk of cigarciic smoking is siill unucrcsii-
maicu in ihc public. 1hc chilurcn anu auolcsccnis arc frc-
gucnily cxposcu io uircci anu inuircci prcssurcs io lighi a
cigarciic. Boih passivc anu aciivc smoking rcmains a grcai
problcm ucspiic ihc lcgal provisions ihai shoulu hclp ihai
as much spacc as possiblc bc frccu from cigarciic smokc.
Smokcrs arc mosily muliiplc paiicnis. 1hcy morc frc-
gucnily suffcr from chronic uiscascs ihai rcguirc longicrm
ircaimcni, morc frcgucnily rcguirc hospiializaiion, arc on
sick-lcavc, bccomc uisablcu, anu uic prcmaiurcly. 1hcrc
is no hcalihy lcvcl of cigarciic smoking.
On ihc oihcr hanu, guiiiing smoking is accompanicu
by numcrous auvaniagcs - physical, cmoiional, social anu
cconomic. Among ihc auvaniagcs of guiiiing smoking, ihc
rcuuciion in ihc risk of sirokc ccriainly is onc of ihc mosi
imporiani, as ii is known ihai onc ihiru of sirokc paiicnis
uic, onc ihiru havc io livc wiih minor or major uisabiliiy,
anu only onc ihiru rccovcr.
24 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
S1RLS ! MOZDAN! UDAR
STR!SS A^! STROK!
Marinko Dikanovi
Dcparimcni of Ncurology, Dr. ]osip Bcnccvi Gcncral Hospiial, Slavonski Brou, Croaiia
Oujcl za ncurologiju, Opa bolnica Dr. ]osip Bcnccvi", Slavonski Brou
1ouay, mosi pcoplc arc pcrmancnily cxposcu io chronic
sircss uuc io ihc cvcr fasicr living imposcu by ihc moucrn
lifcsiylc. !n Croaiia, cvcn grcaicr proporiion of ihc popu-
laiion arc cxposcu io sircss uuc io ihc conscgucnccs of rc-
ccni war aciions. Alihough sircss ccriainly is onc of ihc risk
faciors for ihc ucvclopmcni of ccrcbrovascular uiscascs,
ihcrc arc many uoubis aboui ihc cxaci ucfiniiion of ihc
sircss conccpi, anu cspccially of ihc way of mcasuring
sircss scvcriiy. A Canauian physician H. Sclyc was ihc firsi
io ucfinc sircss as spiriiual or physical ovcrloauing of ihc
bouy by cxhausiion. 1hc sircss anu sircssors ihai provokc
sircss arc uiviucu inio acuic anu longlasiing or chronic
oncs, howcvcr, ihc laiicr is primarily consiucrcu as a risk
facior for sirokc. Various ncurobiological changcs in ihc
bouy inuuccu by sircss arc wcll known, c.g., aciivaiion of
ihc ncurohumoral hypoihalamo-piiuiiary-aurcnal axis wiih
conscgucniial prouuciion of ihc sircss hormonc coriisol.
Bcsiucs ihis, sircss aciivaics ihc prouuciion of ihc ncu-
roiransmiiicrs aurcnalinc anu noraurcnalinc, anu siimu-
laics aciivaiion of ihc rcnin-angioicnsin sysicm, which in
iurn rcsulis in an cnhanccu prouuciion of angioicnsin !!,
which uliimicly prccipiiaics ihc ucvclopmcni of aihcro-
sclcrosis. !n paiicnis wiih chronic posiiraumaiic sircss
uisorucr (I1SI), prolongcu prouuciion of coriisol, aurc-
nalinc anu noraurcnalinc uuc io uysfunciion of posiiivc
fccuback mcchanism has bccn ucmonsiraicu, which rc-
sulicu in ihc vasospasm of ihc circlc of Willis vcsscls in as
many as 627 of paiicnis in somc siuuics. As a highcr prc-
valcncc of oihcr risk faciors has also bccn rccorucu in I1SI
paiicnis, ii suggcsis ihai ihcsc paiicnis arc ai a highcr risk
of sirokc. 1ouay ii is known ihai chronic sircss also has an
immunosupprcssivc aciion, anu lcaus io granulocyic, anu
1 anu B lymphocyic couni uccrcasc, anu ihus io naiivc anu
ccllular immuniiy impairmcni, which ihcn coniribuics io
ihc morbiuiiy anu morialiiy incrcasc. Irolongcu sircss also
siimulaics ihc ucvclopmcni of aricrial hypcricnsion,
which is ihc major risk facior for sirokc. 1hcrc arc a num-
bcr of siuuics poiniing io ihc rolc of sircss as a risk facior
for sirokc. War is ucfiniicly onc of ihc sirongcsi sircssors,
U uanasnjcm moucrnom svijciu jc prakiicno vcina
ljuui zbog samog ubrzanog nacina zivoia pou sialnim uijc-
cajcm kronicnog sircsa, a u nasoj jc zcmlji broj ljuui pou
sircsom jos i vci zbog posljcuica ncuavno zavrscnog raia.
!ako jc sircs ncuvojbcno jcuan ou cimbcnika rizika za raz-
voj ccrcbrovaskularnc bolcsii, posioji niz uvojbi o iocnom
ucfiniranju pojma sircsa ic osobiio o nacinima mjcrcnja
jacinc" sircsa. Kanaoanin H. Sclyc jc prvi lijccnik koji jc
sircs ucfinirao kao uuscvno ili ijclcsno prcopicrccnjc or-
ganizma iscrpljcnosu. Sam sircs kao i sircsori koji ga iza-
zivaju uijclc sc na akuinc i uugoirajnc ili kronicnc, ali sc
kao na cimbcnik rizika za mozuani uuar prvcnsivcno misli
na uugoirajni sircs. Ioznaic su raznc ncurobioloskc pro-
mjcnc u organizmu pou uijccajcm sircsa. 1ako, primjcricc,
sircs akiivira ncurohumoralni hipoialamo-hipofizno-
aurcnalni susiav s posljcuicnim sivaranjcm sircs hormona
koriizola. Uz io, sircs akiivira sivaranjc ncuroiransmiicra
aurcnalina i noraurcnalina, ic poiicc akiiviranjc rcnin-an-
gioicnzinskog susiava, sio rczuliira povcanom proizvou-
njom angioicnzina !!., sio pak u konacnici ubrzava razvoj
aicrosklcrozc. Kou bolcsnika s kronicnim posiiraumaiskim
sircsnim porcmcajcm (I1SI) uokazana jc prouuzcna
proizvounja koriizola, aurcnalina i noraurcnalina, i io zbog
ncfunkcioniranja mchanizma poziiivnc povrainc sprcgc,
sio jc u nckim rauovima rczuliiralo vazospazmom krvnih
zila Willisova kruga kou cak 627 ovih bolcsnika. Kako jc
kou bolcsnika koji boluju ou I1SI-a uokazana povcana
uccsialosi i urugih cimbcnika rizika, io upuujc na zaklju-
cak ua bolcsnici koji boluju ou ovc bolcsii imaju povcan
rizik za nasianak mozuanog uuara. Danas sc zna kako kro-
nicni sircs ima i imunosuprcsivno ujclova-njc, ic ua uovo-
ui uo paua broja granulociia, 1 i B limfociia i iako oslab-
ljujc uroocnu i sianicnu imunosi, sio uoprinosi povcanju
morbiuiicia i morialiicia.
Dugoirajan sircs iakoocr poiicc razvoj aricrijskc hi-
pcricnzijc koja jc sama po scbi najznacajniji cimbcnik rizi-
ka za nasianak mozuanog uuara. Iosioji niz rauova koji na
ncizravan nacin pokazuju znaccnjc sircsa kao cimbcnika
rizika za razvoj mozuanog uuara. Rai jc ncuvojbcno jcuan
ou najjacih sircsora, sio jc pokazano u rauovima koji su
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 25
uokazali znacajno povcan broj bolcsnika koji su zauobili
iniraccrcbralno krvarcnjc i subarahnoiuno krvarcnjc na
pourucju Osijcka za vrijcmc rainih zbivanja u ounosu na
mirnouopsko razuobljc. 1ijckom rainih gouina jc i u Sara-
jcvu znacajno povcana inciucncija mozuanih uuara, i io
osobiio hcmoragijskog u ounosu na razuobljc prijc raia.
Siuuijc kojc su analiziralc uijccaj uugoirajnog sircsa na
cimbcnikc rizika za razvoj ccrcbrovaskularnc bolcsii su
pokazalc kako jc u skupini rainih siraualnika-prognanika
siaiisiicki znacajno vci uuio bolcsnika koji boluju ou aric-
rijskc hipcricnzijc, hipcrlipiucmijc i prciilosii u ounosu na
konirolnu skupinu, sio uouaino ukazujc na io ua sircs - uz
io sio jc sam po scbi cimbcnik rizika - poiicc i razvoj urugih
cimbcnika rizika za nasianak mozuanog uuara. 1akoocr
posiojc rauovi koji su u skupini prognanika uokazali po-
vcan broj bolcsnika s mozuanim uuarom u ounosu na opu
populaciju. Na osnovi uosauasnjih spoznaja mozcmo zak-
ljuciii kako jc prolongirani sircs ncuvojbcno jcuan ou cim-
bcnika rizika za nasianak mozuanog uuara, poglaviio
hcmoragijskog, ali kako on posrcuno mozc uouaino uiijc-
caii i na povcanjc uccsialosii i urugih cimbcnika rizika za
razvoj ccrcbrovaskularnc bolcsii.
as shown in ihc siuuics ucmonsiraiing a significanily grcai-
cr numbcr of paiicnis wiih iniraccrcbral hcmorrhagc anu
subarachnoiu hcmorrhagc in ihc Osijck arca uuring ihc war
as comparcu wiih ihc pcacciimc pcriou. A significani in-
crcasc in ihc inciucncc of sirokc, cspccially of hcmorrhag-
ic iypc of sirokc, was also rccorucu in Sarajcvo uuring ihc
war as comparcu wiih ihc pcacciimc pcriou. Siuuics ana-
lyzing ihc cffcci of prolongcu sircss on ihc risk faciors for
ccrcbrovascular uiscasc havc shown a siaiisiically signifi-
canily highcr proporiion of paiicnis wiih aricrial hypcricn-
sion, hypcrlipiucmia anu obcsiiy in ihc group of war suf-
fcrcrs-rcfugccs ihan in ihc conirol group of subjccis, ihus
auuiiionally poiniing io sircss aciing as boih a risk facior
by iisclf anu siimulaiing ihc ucvclopmcni of oihcr risk
faciors for sirokc. Oihcr siuuics havc ucmonsiraicu an
incrcascu proporiion of sirokc paiicnis in ihc group of
rcfugccs as comparcu wiih ihc gcncral populaiion. Accoru-
ingly, ihc prcscni knowlcugc aboui sircss inuicaics ihai
prolongcu sircss is ucfiniicly onc of ihc risk faciors for
sirokc, cspccially for hcmorrhagic sirokc, anu can also au-
uiiionally incrcasc ihc prcvalcncc of oihcr risk faciors for
ihc ucvclopmcni of ccrcbrovascular uiscasc.
1. D!KANOV!C M, KADO]!C D, BAS!C-KLS V, SLR!C V, DLMAR-
!N V. 1ranscranial Dopplcr sonography for posi-iraumaiic sircss uis-
orucr. Mil Mcu 2001;166:955-8.
2. KADO]!C D, OBRADOV!C M, CANDRL!C M, I!LAKOV!C I.
Ncurobiological anu clinical conscgucnccs of posi-iraumaiic sircss
uisorucr. Acia Clin Croai 2000;39:89-94.
3. I!1MAN R, ORR S. 1wcniy-four hour urinary coriisol anu caic-
cholaminc cxiraciion in combai rclaicu posiiraumaiic sircss uisor-
ucr. Biol Isychiairy 1990;27:245-7.
4. SILNCL ]D. Ccrcbral conscgunccs of hypcricnsion: whcrc uo ihcy
lcau: ] Hypcricns Suppl 1996;14:139-45.
5. KADO]!C D, BARAC B. Sircss as a possiblc facior faciliiaiing sub-
arachnoiu hcmorrhagc. Ncurocpiucmiology 2001;20:45-6.
6. KADO]!C D, DLMAR!N V, BOZ!CLV!C D, BALLN1!C V, KA-
DO]!C M. Ircgucncy anu clinical characicrisiics of sponiancous
ccrcbral hcmorrhagc uuring ihc 1991-1992 war. Ncurol Croai
1996;45:7-14.
7. KADO]!C D, ]ANCUL]AK D, BARAC B, KADO]!C M. Hcmor-
rhagic sirokc in ihc Osijck rcgion uuring a ninc-ycar pcriou: !!. Clin-
ical subiypcs, managcmcni, anu ouicomc. Acia Clin Croai 1997;36:
155-9.
8. D!M!1R!]LV!C ], GAVRANOV!C M, DZ!RLO K, BRA1!C M,
HRN]!CA M, BUL!C G, HLB!B Lj. Ccrcbrovascular acciucnis in
Sarajcvo uuring ihc war. Rcv Ncurol 1999;155:359-64.
9. KADO]!C D, DLMAR!N V, KADO]!C M, M!HAL]LV!C !, BARAC
B. !nflucncc of prolongcu sircss on risk faciors for ccrcbrovascular
uiscasc. Coll Aniropol 1999;23:213-9.
10. DLMAR!N V, IODOBN!K-SARKAN]! S, LOVRLNC!C-HUZ]AN
A, RUNDLK 1, 1HALLLR N. Sircs kao fakior rizika za razvoj ncu-
roloskih bolcsii. Acia Clin Croai 1992;31:233-8.
26 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
Main 1opic !!! !!!. glavna icma
AIIROACI!S I^ TI! IR!\!^TIO^ OI STROK!
IRIST\II \ IR!\!^CIJI MOZ!AÔG \!ARA
]osip Iali
Boih Croaiian anu Anglo-Saxon auihors (Maxcy, Wil-
son, Babus) havc rcccnily bccn cvcr morc focuscu on ihc
cpiucmiology anu cxicnsion of ihc ucfiniiion of noncon-
iagious uiscascs (malignani uiscascs, uiscascs of ihc cir-
culaiory sysicm, mcnial uisorucrs, iraumaiism, malnuiri-
iion). Among ihc ccniral ncrvous sysicm uiscascs, ccrc-
brovascular uiscascs occupy ihc lcauing posiiion, anu cv-
cry rcscarch in ihc ficlu coniribuics io ihc soluiion of
sirokc issucs.
1hc laicsi conccpis on sirokc prcvcniion aiiraci cvcr
morc inicrcsi. 1hc high inciucncc, prcvalcncc anu cco-
nomic cosi of sirokc makc ii amcnablc io prcvcniion. 1hc
rcccni prcvcniivc approachcs io sirokc imply iwo main
siraicgics: mass approach anu inuiviuual high risk ap-
proach.
!n mass approach, ihc objcciivc is io siimulaic lifcsiylc
mouificaiions anu io moucraicly lowcr ihc lcvcl of risk
faciors in all inuiviuuals wiihin a populaiion. !nuiviuual
high risk approach auurcsscs inuiviuuals wiih high risk
faciors anu implics usc of mcuicaiion such as aniihypcr-
icnsivcs, siaiins, cic., in an aiicmpi io rcuucc ihc risk of
sirokc. 1hc iwo siraicgics arc complcmcniary in ihc prc-
vcniion of sirokc. Nowauays, ihc manifcsiaiions of sirokc
can bc prcvcnicu by aciing sysicmaiically upon pariicular
faciors ihrough naiional programs for ihcir climinaiion, by
usc of prcvcniivc mcasurcs, anu cspccially by appropriaic
uiciary habiis anu lifcsiylc mouificaiion. Many siuuics
lkLVLN1lCN Cl S1kClL
lkLVLNCl}A MCZDANCC UDAkA
U novijc vrijcmc nasi kao i anglosaksonski auiori (Maxcy,
Wilson, Babus) uaju svc vcu vaznosi cpiucmiologiji i pro-
sircnju ucfinicijc nczaraznih bolcsii (malignc bolcsii, bolcs-
ii cirkulacijskog susiava, mcnialnc bolcsii, iraumaiizam,
ncishranjcnosi). Mcou bolcsiima srcuisnjcga zivcanog
susiava (SZS) ccrcbrovaskularnc bolcsii zauzimaju voucc
mjcsio. Svako njihovo proucavanjc prcusiavlja uoprinos
rjcsavanju problcmaiikc mozuanog uuara. Najnovijc
spoznajc o prcvcnciji mozuanog uuara pobuouju svc vcc
zanimanjc. Visoka inciucncija i uccsialosi ic ckonomski
iroskovi cinc mozuani uuar pogounim za prcvcnciju. Naj-
noviji prcvcniivni prisiupi mozuanom uuaru pourazumi-
jcvaju uvijc glavnc siraicgijc: masovni prisiup - ciji jc cilj
uvouiii promjcnc nacina zivoia i umjcrcno smanjiii razinu
cimbcnika rizika u svih pojcuinaca u populaciji; i inuivi-
uualni prisiup visokog rizika - koji sc ounosi na osobc s vi-
sokim cimbcnicima rizika, a pourazumijcva upoircbu lijc-
kova kao sio su aniihipcricnzivi, siaiini i ur. u cilju sma-
njivanja rizika mozuanog uuara. Ovc su uvijc siraicgijc kom-
plcmcniarnc u prcvcnciji mozuanog uuara. Danas sc mani-
fcsiacijc mozuanog uuara mogu sprijcciii sisicmaiskim
uijccajima na pojcuinc cimbcnikc, nacionalnim programi-
ma u suzbijanju nckih cimbcnika rizika ic pouuzimanju
prcvcniivnih mjcra, a osobiio nacinom prchranc i mijcn-
janjcm zivoinih navika. Mnogobrojna isirazivanja ukazala
su na posiojanjc cimbcnika rizika koji uvjciuju razvoj i ishou
mozuanog uuara. 1i bi sc cimbcnici mogli pouijcliii u uvijc
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 27
skupinc, ij. na unuiarnjc cimbcnikc rizika u kojc ubraja-
mo aricrijsku hipcricnziju, srcanc bolcsii, sccrnu bolcsi,
auipoziici, promjcnc hcmaiokriia, poviscnu razinu fibri-
nogcna, poviscnc masnoc u krvi, uznaprcuovalu aicro-
sklcrozu; ic vanjskc cimbcnikc rizika kao sio su puscnjc,
konzumacija alkohola, ijclcsna ncakiivnosi, mcicoroloski
cimbcnici, ncpravilna prchrana, uzimanjc nckih lijckova.
Zanimljiv jc siav ncurocpiucmiologa Boniic koji kronologi-
ju ciiopaiogcnczc mozuanog uuara svoui na uva zbivanja:
prvcnsivcna jc osnova gcnciska prcuispozicija na koju sc
nauopunjuju vanjski cimbcnici. Aricrijska hipcricnzija
najznacajniji jc cimbcnik rizika za pojavu ccrcbrovasku-
larnih bolcsii. Iraminghamska siuuija ukazujc na io ua
osobc s usianovljcnom hipcricnzijom imaju uvosiruko vci
rizik za mozuani uuar ncgo onc s normalnim ilakom. Oni
koji su na granici aricrijskc hipcricnzijc imaju 507 vci rizik
za mozuani uuar. Dislipiucmija jc uobro uicmcljcn cimbc-
nik rizika za koronarnc bolcsii, ali jc njc-zina povczanosi s
mozuanim uuarom osiala ncjasna, mozua zbog hcicrogcnc
naravi uuara. Irakcija kolcsicrola HDL ima obrnui uijccaj
na razvoj aicrosklcrozc, uok poviscnjc frakcijc LDL izravno
uijccc na inciucnciju bolcsii srca. Irilikom puscnja uolazi
uo osiccnja cnuoicla aricrijskc siijcnkc, a povcava sc
konccniracija karboksihcmoglobina u krvi, sio smanjujc
prijcnos kisika uo sianica i uvjciujc hipoksiju. Ovisnosi o
puscnju uovoui uo poviscnja LDL-a i snizcnja HDL-a u
krvi, a pri prcsianku puscnja uolazi uo rcgrcsijc aicrosklc-
rozc, a iimc i uo smanjcnja rizika. Zakljucujcmo kako bi
svcopim nasiojanjima ircbalo priuruziii i prcvcnciju raz-
voja srcanih bolcsii, s obzirom na io ua su mozuani uuar i
srcanc bolcsii u visokoj mcouovisnosii. Svi lijccnici, po-
glaviio oni u primarnoj zuravsivcnoj zasiiii, ircbali bi sc
uouaino obrazovaii o mcuikamcninim i ncmcuikamcni-
nim nacinima prcvcniivnog ujclovanja, pogoiovo o vaznosii
susiavnc konirolc krvnog ilaka, svcobuhvainim programi-
ma koji upozoravaju na sicinosi puscnja i prckomjcrnc
konzumacijc alkohola, uijciciskim savjciovanjcm, ic o far-
makoloskom znaccnju uzimanja lijckova koji snizavaju
masnoc u krvi i urugim nacinima voocnja zuravog zivoia
kao sio jc rcuoviia ijclovjczba. Siovisc, lijccnici bi sc irc-
bali inicnzivno obrazovaii u posiavljanju pravilnih inuikaci-
ja za primjcnu aniikoagulaninc i aniiiromboiskc icrapijc,
zaiim o inuikacijama za karoiiunu cnuaricrckiomiju kou
karuiovaskularnih bolcsnika, kao i raui prcvcncijc mozua-
nog uuara.
Srcunjoskolcc i mlaui ouraslc ljuuc ircba biii poscbno
upozoravaii na sicinosi puscnja i io bi ih saznanjc ircbalo
obcshrabriii u sivaranju navikc puscnja. Obrazovanjc irc-
ba biii povczan s pravnim i ckonomskim mjcrama kojc
pouupiru masovni prisiup prcvcnciji.
havc poinicu io ihc cxisicncc of risk faciors influcncing
ihc ucvclopmcni anu ouicomc of sirokc. 1hcsc faciors can
bc uiviucu inio iwo groups: inirinsic anu cxirinsic risk fac-
iors.
!nirinsic risk faciors incluuc aricrial hypcricnsion, car-
uiac uiscascs, uiabcics mclliius, auiposiiy, hcmaiocrii
impairmcni, incrcascu fibrinogcn, incrcascu bloou lipius,
anu auvanccu aihcrosclcrosis. Lxirinsic risk faciors arc ciga-
rciic smoking, alcohol consumpiion, physical inaciiviiy,
wcaihcr faciors, inappropriaic uiciary habiis, anu somc
urugs.
Accoruing io Boniia, a ncurocpiucmiologisi, ihc ciio-
paihogcncsis of sirokc can bc chronologically rcuuccu io
iwo cvcnis: ii is primarily unucrlaiu by gcnciic prcuispo-
siiion, supcrimposcu by ihc cxirinsic faciors.
Aricrial hypcricnsion is ihc major risk facior for ihc
ucvclopmcni of ccrcbrovascular uiscasc. Iramingham
siuuy has shown ihai subjccis wiih csiablishcu hypcricn-
sion arc ai a iwofolu risk of sirokc ihan ihc subjccis wiih
normal bloou prcssurc, anu in ihosc wiih borucrlinc valu-
cs of bloou prcssurc ihc risk of sirokc is grcaicr by 507.
Dyslipiucmia is a wcll csiablishcu risk facior for coronary
uiscascs, howcvcr, iis associaiion wiih sirokc rcmains ob-
scurc, pcrhaps uuc io ihc hcicrogcncous naiurc of sirokc.
1hc HDL cholcsicrol fraciion has an invcrsc cffcci on ihc
ucvclopmcni of aihcrosclcrosis, whcrcas an incrcasc in
LDL fraciion uirccily corrclaics wiih ihc inciucncc of
caruiac uiscascs.
Cigarciic smoking causcs lcsion of ihc aricrial wall
cnuoihclium anu clcvaiion of ihc carboxyhcmoglobin con-
ccniraiion in ihc bloou, which in iurn rcuuccs ihc irans-
fcr of oxygcn io ihc cclls anu lcaus io hypoxia. Cigarciic
ucpcnucncc lcaus io LDL incrcasc anu HDL uccrcasc in
ihc bloou, whcrcas ccssaiion of smoking rcsulis in rcgrcs-
sion of aihcrosclcrosis anu ihus in sirokc risk rcuuciion.
Accoruingly, ii is concluucu ihai ihc prcvcniion of car-
uiac uiscascs shoulu bc auucu io ihc ovcrall cfforis in sirokc
prcvcniion, bccausc ihcrc is a sirong inicr-rclaiionship
bciwccn sirokc anu caruiac uiscascs.
All physicians, cspccially ihosc in primary hcalih carc,
shoulu rcccivc auuiiional iraining in mcuicamcnious anu
nonmcuicamcnious moualiiics of prcvcniivc aciion, cspc-
cially on ihc high imporiancc of sysicmaiic bloou prcssurc
conirol, ihrough comprchcnsivc programs warning of ihc
ucirimcnial cffccis of cigarciic smoking, cxccssivc alco-
hol consumpiion; uiciciic counscling; pharmacologic as-
pccis of bloou lipiu lowcring agcnis; anu on all clcmcnis
of hcalihy lifcsiylc such as rcgular physical aciiviiy. 1hc
morc so, physicians shoulu bc inicnscly iraincu in csiab-
lishing corrcci inuicaiions for ihc usc of aniicoagulani anu
aniiihromboiic ihcrapy, anu for caroiiu cnuaricrcciomy in
caruiovascular paiicnis as wcll as for sirokc prcvcniion.
28 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
TI! ROI! OI M!!IA I^ STROK! IR!\!^TIO^
\IOGA M!!IJA \ IR!\!^CIJI MOZ!AÔG \!ARA
Vcljko orocvi
Univcrsiiy Dcparimcni of Isychiairy, Zagrcb Univcrsiiy Hospiial Ccnicr, Zagrcb, Croaiia
Klinika za psihijairiju, Klinicki bolnicki ccniar Zagrcb", Zagrcb
Noi rcccivcu
Nijc primljcno
1ccnagcrs anu young auulis shoulu bc spccially au-
urcsscu by warnings on ihc harmful cffccis of cigarciic
smoking, which informaiion shoulu uiscouragc ihcm io
ucvclop smoking habii. Luucaiion shoulu bc accompanicu
by lcgal anu cconomic mcasurcs ihai suppori ihc mass
approach io sirokc prcvcniion.
1. IAL!C ]. Analiza slucajcva lijcccnog ccrcbrovaskularnog inzulia na
jcunom grauskom pourucju. Magisiarski rau. Mcuicinski fakulici
Zagrcb, 1980:1.
2. GORLL!CK I. Irogrcss in ihcrapy of ischcmic sirokc prcvcniion.
Ncurol Croai 1996;45 (Suppl 3):6.
3. BARAC B. Lpiucmiologija ccrcbrovaskularnih bolcsii. U: Ncurologi-
ja. Zagrcb, 1992.
4. BON!1A R. Lpiucmiology of sirokc. Lancci 1992;339:342-4.
5. SACCO RL. Risk faciors anu ouicomcs for ischcmic sirokc. Ncu-
rology 1995;45 (Suppl 1):S10-S14.
6. HACH!NSK! V, IRAIIAGN!NO C, BLAUDRY M, BLRN!LR G,
BUCK C, DONNLR A, SILNCL ]D, DO!G G, WOLIL BM. Lip-
ius anu sirokc: a parauox rcsolvcu. Arch Ncurol 1996;53:303-8.
7. DLMAR!N V. Mozuani krvoiok (klinicki prisiup). Liiopaiogcncza
i fakiori aicrosklcrozc. Zagrcb: 1994:30-7.
A^TIOXI!A^TS A^! !I!T I^ TI! IR!\!^TIO^ OI
C!R!HRO\ASC\IAR !ISOR!!RS
A^TIOKSI!A^SI I ÂCI^ IR!IRA^! \ IR!\!^CIJI
C!R!HRO\ASK\IARÎI OST!C!^JA
Davor ]anculjak
1hc causal rclaiionship bciwccn ihc iypc of uici anu
ucvclopmcni of sirokc has noi bccn fully invcsiigaicu.
Largc ccologic siuuics inuicaic ihai cxccssivc iniakc of
uicicry fai coulu bc associaicu wiih an incrcascu risk of
Ncposrcuna povczanosi uzimanja ourcocnc vrsic hranc
i nasianka mozuanog uuara jos uvijck nijc uovoljno
isirazcna. Vclikc ckoloskc siuuijc ukazuju na io ua prcko-
mjcrno uzimanjc masnoa u hrani nosi poviscn rizik za
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 29
sirokc anu coronary ischcmic uiscasc. 1hc Iramingham
siuuy, on ihc oihcr hanu, has founu an invcrsc corrclaiion
bciwccn uiciary fai anu ischcmic sirokc. !n auuiiion io fai,
largc guaniiiics of sali in ihc uici incrcasc ihc risk of sirokc
uuc io ihc bloou prcssurc clcvaiion. Anoihcr uiciary ingrc-
uicni ihai may influcncc circulaiory uiscsasc is clcvaicu
homocysicin. 1hc Iramingham siuuy has ucmonsiraicu
ihai folaic, anu viiamin B12 anu B6 ucficiis arc ihc mosi
common causc of hypcrhomocysicincmia in ihc risk
groups. Accoruing io casc-conirol siuuics, subsiiiuiion of
B6 viiamin may uccrcasc ihc risk of sirokc. Daily uiciary
iniakc of fruii anu vcgciablcs may havc a favorablc cffcci
in ihc prcvcniion of sirokc, bccausc ihcy coniain aniioxi-
uanis (viiamins C anu L, anu proviiamin A) ihai ncuiral-
izc frcc rauicals aficr LDL cholcsicrol oxiuaiion anu ihus
prcvcni ihc occurrcncc of aihcrosclcroiic plagucs.
mozuani uuar i koronarnu srcanu bolcsi. Iraminghamska
siuuija pak ukazujc na obrnuiu povczanosi izmcou mas-
noa u prchrani i nasianka ishcmijskog mozuanog uuara.
Uz masnoc, povcano soljcnjc hranc povcava rizik
mozuanog uuara, jcr uovoui uo hipcricnzijc. Sljcuci cim-
bcnik u prchrani koji mozc ncpovoljno ujclovaii na cirku-
lacijskc bolcsii jc poviscni homocisicin. Iraminghamska
siuuija pokazujc ua jc manjak folaia, viiamina B 12 i B 6
najccsi uzrok poviscnja homocisicina u ugrozcnim skupi-
nama. 1akoocr, nauoknaua viiamina B6 mozc, prcma kon-
iroliranim klinickim siuuijama, smanjiii rizik za mozuani
uuar. Uzimanjc voa i povra u svakouncvnoj prchrani mozc
povoljno ujclovaii u prcvcnciji mozuanog uuara. Ovc namir-
nicc saurzc aniioksiuansc (viiamini C i L, proviiamin A)
koji ujcluju na slobounc rauikalc nasialc oksiuacijom LDL
kolcsicrola i iako sprjccavaju aicrosklcroiskc plakovc.
IIYSICAI ACTI\ITY I^ TI! IR!\!^TIO^ OI STROK!
TJ!I!SÂ AKTI\ÔST \ IR!\!^CIJI MOZ!AÔG \!ARA
Mira Kauoji
Dcparimcni of Ihysical Mcuicinc anu Rchabiliiaiion, Osijck Univcrsiiy Hospiial, Osijck, Croaiia
Oujcl za fizikalnu mcuicinu i rchabiliiaciju, Klinicka bolnica Osijck, Osijck
Iojam ijclcsnc akiivnosii ounosi sc na misini rau s
ougovarajuim povcanjcm cncrgciskc poirosnjc iznau
razinc mirovanja. U visokoinuusirijaliziranom svijciu ijc-
lcsni rau iscczava prcu mchanizacijom i roboiikom, a ijc-
lcsna ncakiivnosi posiajc vazan rizicni cimbcnik za razvoj
mnogih kronicnih bolcsii. Smaira sc ua jc najmanjc pcucsci
posio promjcna kojc sc pripisuju siarcnju u populaciji raz-
vijcnog svijcia uzrokovano airofijom uslijcu ncakiivnosii.
Sioga zabrinjava pouaiak ua u razvijcnim zcmljama 607 uo
857 ouraslih zivc scuanicrnim nacinom zivoia. Iosiojc
brojni znansivcni uokazi o povczanosii razinc ijclcsnc ak-
iivnosii i zuravlja, a najvisc jc rauova koji uokazuju povc-
zanosi rcuoviic ijclovjczbc i smanjcnja inciucncijc morbiui-
icia ou koronarnc bolcsii srca, sccrnc bolcsii ncovisnc o
inzulinu, karcinoma ucbclog crijcva ic osicoporozc i njczi-
nih klinickih manifcsiacija. Rcuoviia ijclcsna akiivnosi
ougovarajuc vrsic, inicnziicia, irajanja i uccsialosii pobolj-
sava fizicku sposobnosi, ponajprijc poboljsanjcm ucin-
koviiosii iransporinog susiava za kisik, boljim uiroskom
1hc icrm physical aciiviiy rcfcrs io musclc work wiih
a corrcsponuing incrcasc in cncrgy consumpiion abovc ihc
lcvcl ai rcsi. !n inuusirializcu counirics, physical work has
bccn vanishing uuc io mcchanizaiion anu roboiics, anu
physical inaciiviiy is bccoming an imporiani risk facior for
ihc ucvclopmcni of many chronic uiscascs. !i is csiimai-
cu ihai ai lcasi 507 of changcs aiiribuicu io aging in ihc
populaiion of ihc inuusirializcu worlu arc causcu by airo-
phy uuc io inaciiviiy. !i is uisiurbing io lcarn ihai in uc-
vclopcu counirics, 607 io 857 of auulis livc a scucniary
siylc of lifc. 1hcrc is sirong scicniific cviucncc for ihc
associaiion bciwccn ihc lcvcl of physical aciiviiy anu
hcalih, anu mosi siuuics ucmonsiraic an associaiion of
rcgular cxcrcisc wiih a uccrcasc in ihc inciucncc of coro-
nary hcari uiscasc, non-insulin ucpcnucni uiabcics mcl-
liius, colon carcinoma, anu osicoporosis anu iis clinical
manifcsiaiions.
Rcgular physical aciiviiy of appropriaic iypc, inicnsi-
iy, uuraiion anu frcgucncy improvcs physical abiliiy, pri-
30 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
cncrgciskih ivari ic poboljsanjcm rcgulacijskih mchaniza-
ma zivcanog susiava. Acrobni kapaciici visoko akiivnih
osoba smanjujc sc samo 17-27 za svako ucsciljcc zivoia,
uok jc u ijclcsno ncakiivnih osoba ovaj pau viscsiruko vci.
Ioziiivni ucinci ijclcsnc akiivnosii na ljuuski organizam
oglcuaju sc u slijcuccm: ijclcsna akiivnosi uijccc na sma-
njcnjc ijclcsnc iczinc, a uuruzcna s pravilnom prchranom
pomazc u njczinoj uugorocnoj koniroli, ic siiii ou razvoja
aicrosklcrozc; mijcnja lipoproicinski profil povcanjcm
konccniracijc HDL kolcsicrola i smanjcnjcm razinc scrum-
skih irigliccriua; poboljsava mciabolizam ugljikohiuraia i
snizava inzulin u scrumu; snizava sisicmski krvni ilak u
mirovanju i za vrijcmc napora; smanjujc aurcncrgicnc po-
sljcuicc sircsa; smanjujc agrcgaciju iromobociia i povca-
va fibrinolizu; cuva kosianu masu i siiii ou osicoporozc;
poboljsava pokrciljivosi, snagu i izurzljivosi, poboljsava
raspolozcnjc i poiicc samopouzuanjc. Da bi ijclovjczba bila
korisna ona mora biii rcuoviia, uccsiala (najmanjc uva uo
iri puia na ijcuan, najboljc svakouncvno), ougovarajucg
inicnziicia (najccsc umjcrcnog i/ili prilagoocnog prcma
kriicrijima fizioloskc siarosii osobc) ic ougovarajucga ira-
janja. Ircporucujc sc barcm 30 minuia krcianja, ounosno
akiivnosii kojc ukljucuju rau vclikih misinih skupina kroz
uuzc vrijcmc, a ouabiru sc prcma zuravsivcnom sianju i
sklonosiima osobc ounosno bolcsnika: pjcsaccnjc, brzo
houanjc, plivanjc, voznja biciklom, vrilarcnjc, obavljanjc
kuanskih poslova, uporaba siubisia umjcsio lifia i sl. Li-
icraiurni pouaci o uijccaju ijclcsnc akiivnosii na primar-
nu i sckunuarnu prcvcnciju mozuanog uuara su konirovcrz-
ni. !pak, vcina prospckiivnih siuuija pokazala jc ua fizic-
ka akiivnosi smanjcnjujc rizik za mozuani uuar. Rczuliaii
provcucnih siuuija ukazuju na io ua jc ia korisi prisuina u
oba spola, u mlaoih i siarijih osoba, kao i u osoba s ili bcz
prcihounc koronarnc bolcsii. Iriiom sc nc navouc spori-
skc akiivnosii kao ncophounc. Umjcrcna razina ijclcsnc
akiivnosii mozc biii uovoljna za posiizanjc znacajnog sma-
njcnja rizika ou mozuanog uuara, kao i opcniio smanjcnja
karuiovaskularnog rizika.
marily by improving ihc cfficicncy of ihc oxygcn iranspori
sysicm, bciicr uiilizaiion of cncrgy subsianccs, anu im-
provcmcni of ihc ncrvous sysicm rcgulaiory mcchanisms.
Acrobic capaciiy of highly aciivc pcrsons uccrcascs by only
17 - 27 p-r uccauc of lifc, whcrcas in physically inaciivc
inuiviuuals ihis uccrcasc is iwofolu.
1hc favorablc cffccis of physical aciiviiy on ihc human
bouy rcflcci in ihc following: physical aciiviiy rcsulis in
bouy wcighi rcuuciion; in combinaiion wiih appropriaic
uiciary habiis ii hclps in longicrm bouy wcighi rcgulaiion;
proiccis from ihc ucvclopmcni of aihcrosclcrosis; moui-
fics lipoproicin profilc by incrcasing HDL cholcsicrol anu
uccrcasing scrum iriglyccriucs; improvcs ihc mciabolism
of carbohyuraics anu lowcrs scrum insulin; lowcrs sysicmic
bloou prcssurc ai rcsi anu on cxcrcisc; rcuuccs aurcncrgic
conscgucnccs of sircss; uccrcascs plaiclci aggrcgaiion anu
incrcascs fibrinolysis; proiccis bonc mass anu proviucs
proicciion from osicoporosis; improvcs mobiliiy, sircngih
anu cnuurancc; improvcs ihc moou anu siimulaics sclf-
confiucncc.
Ior ihc physical aciiviiy io bc rcally uscful ii shoulu bc
rcgular, frcgucni (ai lcasi iwicc a wcck, or uaily ai bcsi),
of appropriaic inicnsiiy (mosily moucraic anu/or mouificu
accoruing io ihc criicria of ihc inuiviuual`s physiologic agc),
anu of appropriaic uuraiion. Ai lcasi 30 minuics of movc-
mcni arc rccommcnucu, incluuing aciiviiics ihai imply ihc
work of largc musclc groups for a longcr pcriou of iimc anu
choscn accoruing io ihc subjcci`s or paiicni`s hcalih con-
uiiion anu prcfcrcnccs: walking, fasi walking, swimming,
cycling, garucning, housc work, climbing siairs insicau of
using clcvaior, cic.
Liicraiurc uaia on ihc cffcci of physical aciiviiy on ihc
primary anu scconuary prcvcniion of sirokc arc conirovcr-
sial, howcvcr, mosi prospcciivc siuuics havc shown ihai
physical aciiviiy rcuuccs ihc risk of sirokc. Rcsulis of ihc
siuuics suggcsi ihcsc bcncficial cffccis io bc prcscni in
boih scxcs, in boih young anu clucrly inuiviuuals, anu in
ihosc wiih or wiihoui prcvious coronary uiscasc. Spori
aciiviiics arc noi mcniioncu as absoluicly ncccssary, as a
moucraic lcvcl of physical aciiviiy can bc sufficicni io
achicvc a significani rcuuciion in ihc risk of sirokc anu
caruiovascular risk in gcncral.
1. M!S!GO]-DURAKOV!C M, -t c/. 1jclcsno vjczbanjc i zuravljc.
Zagrcb: Iakulici za fizicku kuliuru Svcucilisia u Zagrcbu, 1999.
2. CA1!IOV!C-VLSLL!CA K, CA1!IOV!C B. Do zuravog srca uijc-
iom i nacinom zivljcnja. Osijck, 1993.
3. IA1L RR, IRA11 M, BLA!R SN, -t c/. Ihysical aciiviiy anu pub-
lic hcalih: a rccommcnuaiion from ihc Ccnicrs for Discasc Conirol
anu ihc Amcrican Collcgc of Sporis Mcuicinc. ]AMA 1995;273:402-7.
4. !nicrnaiional Icucraiion of Sporis Mcuicinc. Ihysical cxcrcisc an im-
poriani facior for hcalih: a posiiion siaicmcni from ihc !nicrnaiional
Icucraiion of Sporis Mcuicinc. !ni ] Sporis Mcu 1989;10:460-1.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 31
Main 1 opic !V !V. glavna icma
DlACNCSlS Cl S1kClL
Dl}ACNCS1llA MCZDANCC UDAkA
CIASSIIICATIO^, CIIÎCAI SIG^S
A^! SYMITOMS OI STROK!
KIASIIIKACIJA I KIIÎCKA SIIKA MOZ!AÔG \!ARA
Slava Iouobnik-Sarkanji
Sirokc is a clinical synuromc characicrizcu by an acuic
loss of focal brain funciion lasiing for morc ihan 24 hours
or lcauing io ucaih, which is ihoughi io bc uuc io ciihcr
sponiancous hcmorrhagc inio or ovcr ihc brain subsiancc
(primarily iniraccrcbral or subarachnoiu hcmorrhagc, i.c.
hcmorrhagic sirokc) or inaucguaic bloou supply io a pari
of ihc brain as ihc rcsuli of low bloou flow, ihrombosis or
cmbolism associaicu wiih uiscascs of ihc bloou vcsscls,
hcari or bloou (ischcmic sirokc, ccrcbral infarciion). 1ran-
sicni ischcmic aiiack (1!A) of ihc brain is ihc samc cvcni
as ischcmic sirokc as ucfincu abovc, bui ihc sympioms
rcsolvc wiihin 24 hours. Oncc ihc uiagnosis of a 1!A or
sirokc has bccn csiablishcu, ihc ncxi sicp is io localizc ihc
pari of ihc brain anu vascular sysicm ihai has bccn affcci-
cu. 1his ucpcnus on ihc basic knowlcugc of ncuroanaio-
my, ccrcbrovascular anaiomy anu common clinical sirokc
synuromcs.
Curotid und \crtcbrobusiIur Tcrritory Ischcniu
Bloou supply io ihc brain is uclivcrcu by ihc iwo in-
icrnal caroiiu anu iwo vcricbral aricrics, which anasiamosc
ai ihc basc of ihc brain io form ihc circlc of Willis. 1hc
caroiiu aricry sysicm supplics ihc anicrior iwo-ihirus of
ihc brain (anicrior circulaiion), anu ihc vcricbrobasilar
aricrial sysicm supplics ihc posicrior ihiru of ihc brain
(posicrior circulaiion).
Mozuani uuar jc klinicki sinurom uzrokovan akuinim
gubiikom mozuanc funkcijc koji irajc uuljc ou 24 saia ili
uovoui uo smrii, a nasiajc zbog sponianog krvarcnja (in-
iraccrcbralnog ili subarahnoiunog) ili pak mozuanc ishc-
mijc uzrokovanc hcmouinamski, irombozom ili cmbolijom,
povczano s promjcnama na samim krvnim zilama ili srca-
nom bolcsu (ishcmijski mozuani uuar - mozuani infarki).
1ranziiorna ishcmijska aiaka (1!A) mozga jc usivari isio
zbivanjc kao ishcmijski mozuani uuar, ali sc simpiomi po-
vlacc unuiar 24 saia. Kaua sc posiavi uijagnoza 1!A-c ili
mozuanog uuara, sljcuci korak jc usianoviii mjcsio u
mozgu i aricriju koji su zahvacni. 1o ovisi o bazicnim
spoznajama o ncuroanaiomiji, ccrcbrovaskularnoj anaiomiji
i sinuromima koji nasiaju kou mozuanog uuara.
Ishcniju u kurotidnon i vcrtcbrobuziIurnon sIivu
Mozak krvlju opskrbljuju uvijc unuiarnjc karoiiunc i
uvijc vcricbralnc aricrijc kojc anasiomoziraju na bazi mozga
ivorci Willisov krug. Karoiiunc aricrijc opskrbljuju krvlju
prcunjc uvijc ircinc mozga (prcunja cirkulacija), a vcric-
brobazilarni susiav opskrbljujc krvlju siraznju ircinu
mozga (siraznja cirkulacija). Okluzija unuiarnjc karoiiunc
aricrijc, ako jc simpiomaiska, obicno uajc simpiomc ishc-
mijc icriiorija srcunjc mozuanc aricrijc, ali ofialmicna i
prcunja mozuana aricrija mogu iakoocr biii ukljuccnc, ovis-
no o kolaicralnoj cirkulaciji. Okluzija unuiarnjc karoiiunc
32 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
aricrijc mozc uzrokovaii monokularno sljcpilo, ispau viu-
nog polja, koniralaicralnu hcmiparczu, hcmihipcsicziju,
uisfaziju ili afaziju, slabosi koniralaicralnc nogc ili siopa-
la, abuliju, inkoniincnciju. !shcmija u vcricbrobazilarnom
pourucju ukljucujc kombinaciju simpioma: iciraparczu,
uiplopiju, vcriigo, koriikalno sljcpilo, ccrcbclarnu aiaksi-
ju. Najccsc jc icsko sa sigurnosu uivruiii koja jc aricrija
uzrok ishcmijc, jcr su pojcuini uijclovi mozga opskrbljcni
krvlju iz karoiiunog i vcricbrobazilarnog sliva. Simpiomi
koji su prisuini i u slucajcvima karoiiunc i vcricbrobazilarnc
ishcmijc su: hcmiparcza, hcmihipcsiczija, uizaririja.
Sindroni kod nozdunog uduru
Sinuromi nasiali mozuanim uuarom zasnivaju sc na
klinickoj slici i mogu sc rcucfiniraii pomou kompjuiori-
ziranc iomografijc mozga. Oni uaju informaciju o anaiom-
skoj i vaskularnoj lokalizaciji lczijc, ciiologiji i prognozi.
Najccsi klinicki sinuromi kou mozuanog uuara su:
1ACS - ioialni anicriorni cirkulacijski sinurom, u oko
207 slucajcva;
IACS - parcijalni anicriorni cirkulacijski sinurom, u oko
307 slucajcva;
LACS - lakunarni cirkulacijski sinurom, u oko 257
slucajcva;
IOCS - posicriorni cirkulacijski sinurom, u oko 257
slucajcva.
Oko 17 bolcsnika s mozuanim uuarom nc ougovara niii
jcunom ou ovih sinuroma.
Mozduni infurkti grunicnih odrucju
!nfarkii granicnih pourucja su infarkii u granicnim
zonama uzmcou uvaju aricrijskih icriiorija. Iosiojc iri glav-
na granicna pourucja:
granicni (povrsni) icriioriji srcunjc mozuanc aricrijc i
prcunjc mozuanc aricrijc u fronioparasagiialnoj rcgiji
(prcunja granicna zona);
povrsni icriiorij izmcou srcunjc i siraznjc mozuanc ar-
icrijc u pariciookcipiialnoj rcgiji (siaznja granicna
zona);
povrsni icriiorij pcnciraninih aricrija i uubokih lcniiku-
losiriaialnih grana srcunjc mozuanc aricrijc u pcrivcn-
irikularnoj bijcloj mozuanoj ivari (subkoriikalna granic-
na zona).
Mozuani infarkii u granicnim pourucjima uglavnom su
uzrokovani smanjcnim proiokom krvi koji mozc nasiaii
zbog naglog paua ilaka (kao kou srcanog arcsia) ili pak kou
okluzijc unuiarnjc karoiiunc aricrijc.
!nicrnal caroiiu aricry occlusion, if sympiomaiic, usu-
ally prouuccs sympioms of ischcmia in ihc miuulc ccrc-
bral aricry icrriiory, bui ihc ophihalmic anu anicrior ccrc-
bral aricry icrriiorics can also bc involvcu, alonc or in com-
binaiion wiih miuulc ccrcbral aricry, ucpcnuing on collai-
cral supply. 1hc occlusion of inicrnal caroiiu aricry may
causc monocular blinuncss or aliiiuuinal ficlu ucfcci; con-
iralaicral hcmiparcsis; hcmiscnsory loss; uysphasia or apha-
sia (uominani hcmisphcrc); coniralaicral fooi anu lcg
wcakncss, abulia, inconiincncc.
Vcricbrobasilar icrriiory ischcmia incluucs a combina-
iion of sympioms: iciraparcsis, uiplopia, vcriigo, coriical
blinuncss, ccrcbcllar aiaxia.
Morc oficn ihan noi, ii is uifficuli io bc ccriain which
aricrial icrriiory is involvcu in an ischcmic cvcni of ihc
brain. 1his is bccausc ccriain paihways rcccivc ihcir bloou
supply from boih ihc caroiiu anu vcricbrobas!lar aricrics
ai uiffcrcni lcvcls. Sympioms anu signs ihai occur wiih ca-
roiiu anu vcricbrobasilar ischcmia incluuc hcmiparcsis,
hcmiscnsory ucficii, uysarihria.
Strokc Syndroncs
1hcsc synuromcs arc bascu on clinical fcaiurcs bui can
bc furihcr rcfincu, if ncccsssary by C1 imaging. 1hcy pro-
viuc valuablc informaiion aboui ihc anaiomical anu vas-
cular locaiion, ciiology, anu prognosis of ihc sirokc. Com-
mon clinical sirokc synuromcs arc:
1ACS, ioial anicrior circulaiion synuromc - aboui 207
of cascs
IACS, pariial anicrior circulaiion synuromc - aboui
307 ou cascs
LACS, lacunar synuromc - aboui 257 of cascs
IOCS, posicrior circulaiion synuromc - aboui 257 of
cascs
aboui 17 of sirokc paiicnis uo noi fii any of ihcsc syn-
uromcs
Houndury (Hordcr) Zonc Infurctions
Bounuary (borucr) zonc infarcis arc infarcis in ihc
borucr zoncs bciwccn aricrial icrriiorics. 1hcrc arc ihrcc
major bounuary zoncs, which lic bciwccn:
ihc supcrficial icrriiorics of ihc miuulc ccrcbral aricry
anu anicrior ccrcbral aricry in ihc fronioparasagiiial rc-
gion (anicrior bounuary zonc)
ihc supcrficial icrriiorics of ihc miuulc ccrcbral aricry
anu posicrior ccrcbral aricry in ihc paricio-occipiial rc-
gion (posicrior bounuary zonc)
ihc supcrficial mcuullary pcnciraiors anu uccp lcniic-
ulosiriaic icrriiorics of ihc miuulc ccrcbral aricry in ihc
paravcniricular whiic maiicr of ihc corona rauiaia (sub-
coriical bounuary zonc)
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 33
^!\ROIMAGI^G (CT A^! MRI)
I^ TI! !IAGÔSIS OI STROK!
^!\ROIMAGI^G M!TO!! (CT I MRI)
\ !IJAGÔSTICI MOZ!AÔG \!ARA
Miljcnko Kalousck, Zoran Rumbolui
Univcrsiiy Dcparimcni for Diagnosiic anu !nicrvcniional Rauiology,
Scsirc milosrunicc Univcrsiiy Hospiial, Zagrcb, Croaiia
Klinicki zavou za uijagnosiicku i inicrvcncijsku rauiologiju,
Klinicka bolnica Scsirc milosrunicc", Zagrcb
Irom 1973, whcn compuicu iomography (C1) was firsi
cmploycu in uiagnosiic work-up of brain uiscascs, ii has
bccomc wiucly uscu in paiicnis wiih vascular brain lcsions.
1hc rolcs of C1 arc muliiplc: visualizaiion of ihc ischcm-
ic proccss in iis carly siagc; cvaluaiion of ihc lcsion; fol-
low-up; anu ucicciion of possiblc complicaiions. Oihcr
imaging icchnigucs arc uscu in sirokc cvaluaiion, howcv-
cr, C1 rcmains ihc firsi moualiiy in mosi cascs anu insii-
iuiions.
C1 icchniguc has bccn significanily improvcu anu
rcfincu ovcr ihc pasi ihrcc uccaucs: ihc numbcr of ucicc-
iors as wcll as spaiial rcsoluiion havc incrcascu, grcaily
improving ihc imagc gualiiy anu ihus visualizaiion of an-
aiomical anu paihological uciails. Wiih ihc inirouuciion of
spiral anu muliislicc scanncrs, ihc imaging iimc has bc-
comc significanily shoricr, wiih auuiiional capabiliiics such
as C1 angiography (C1A).
Larly visualizaiion of lcsions by C1 or magnciic rcso-
nancc imaging (MR!) is crucial for moucrn approach io
sirokc, anu ihc uccision for ihrombolyiic or morc conscr-
vaiivc ircaimcni is bascu on ihc imaging finuings.
1hc basic signs of an acuic (<24 h) ccrcbral infarci in
ihc miuulc ccrcbral aricry (MCA) icrriiory arc: hypcrucnsc
MCA, loss of ihc basal ganglia uciails, uisappcarancc of ihc
insular ribbon, anu asymmcirical narrowing of ihc coriical
sulci. !n a significani proporiion of paiicnis, C1 rcmains
ncgaiivc in ihc firsi 12 hours of ihc infarci.
Ou 1973. gouinc kaua jc kompjuiorizirana iomografija
(C1) uvcucna u uijagnosiiku bolcsii mozga, ona posiajc
mciouom izbora pri zbrinjavanju i lijcccnju bolcsnika s
porcmcajima mozuanc cirkulacijc. Irimarnc su ulogc ovc
mciouc vizualizacija ishcmijskog proccsa u sio ranijoj fazi
bolcsii; procjcna proccsa; pracnjc iijcka bolcsii; ic procjc-
na moguih komplikacija. Danas sc u uijagnosiici mozua-
nog uuara rabc i urugc ichnikc slikovnog prikaza, no C1 i
ualjc osiajc mcioua kojom sc zapocinjc ncurorauioloska
obraua u vcini slucajcva i usianova. S vrcmcnom jc C1
ichnicki znaino unaprijcocn i usavrscn: povcani su broj
ucickiora i prosiorna rczolucija, cimc jc znaino poboljsa-
na kvaliicia snimaka, a iimc i vizualizacija anaiomskih i
paioloskih ucialja. Uvoocnjcm spiralnih i viscslojnih (oe/-
t/s//-) skcncra vrijcmc prciragc jc znaino skracno, uz
uouainc novc mogunosii, kao sio jc C1 angiografija
(C1A). Sio ranija vizualizacija lczija primjcnom C1-a ili
magnciskc rczonancc (MR!) ima kljucnu ulogu u suvrc-
mcnoj uijagnosiici mozuanog uuara, pri oulucivanju za
iromboliiicnu ili konzcrvaiivnu icrapiju. 1cmcljni znaci
akuinog (<24 h) mozuanog uuara u opskrbnom pourucju
aricrijc ccrcbri mcuijc (ACM) su: hipcrucnzna ACM,
brisanjc sirukiurc bazalnih ganglija i koricksa inzulc, ic
asimciricno suzavanjc koriikalnih sulkusa. Znacajan pos-
ioiak bolcsnika ima urcuan C1 mozga u prvih 12 saii na-
kon nasianka inzulia. Za razliku ou C1-a, u vcinc bolcsni-
ka s inzuliom ACM pourucja proccs sc prikazujc MR!-om
Bounuary zonc infarcis arc usually causcu by low flow
io ihc brain. 1his usually occurs in suuucn profounu sys-
icmic hypoicnsion or inicrnal caroiiu aricry occlusion.
34 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
unuiar prvih 24 saia. Unuiar nckoliko saii ou pojavc sim-
pioma iipicno sc nalazc koriikalni cucm, gubiiak uifcrcn-
cijacijc sivc i bijclc ivari (na 12-mjcrcnim, ID i ILA!R
snimkama), hipcrucnzna ACM na ILA!R snimkama, ic
povcno nakupljanjc konirasia u krvnim zilama infarcira-
nog pourucja uslijcu sporijcg proioka. Difuzijskc (d///es/or-
-//t-d, DW!) i pcrfuzijskc (p-r/es/or--//t-d, IW!) ich-
nikc pruzaju osjciljivosi i spccificnosi ou goiovo 1007 vc
u prvom saiu nakon nasiupa inzulia. U subakuinoj fazi (3.-
21. uan) pri obliicraciji ACM u oko 157 slucajcva uolazi
uo sckunuarnog krvarcnja. Giriformna koriikalna imbibicija
konirasiom jc obicno najizrazcnija ou irccga uo scumoga
uana bolcsii. Wallcrianova ucgcncracija uuz zahvacnog
koriikospinalnog puia mozc biii prikazana ou ccivriog ijcu-
na bolcsii. Lnccfalomalacija sc nalazi u kronicnoj fazi. !zo-
lirani infarki opskrbnog pourucja a. ccrcbri anicrior (ACA)
jc rijcuak (<17), ccsc sc nalazi pri okluziji a. karoiis in-
icrnc. Mozc sc javiii kao posljcuica iraumc ili ckspanzivnih
proccsa. !nfarkii u pourucju a. ccrcbri posicrior (ACI)
znaju nasiaii kao posljcuica iransicniorijskc hcrnijacijc, a
u mlauih bolcsnika mogu ukazivaii na vaskuliiis. Okluzija
a. basilaris ccsio uovoui uo smrinog ishoua, a obiljczcna jc
infarkiima razbacanim po infraicniorijalnim ic ACI ops-
krbnim pourucjima. Laminarna nckroza jc poscban cniiici
koji ougovara koriikalnom infarkiu s ocuvanim pojcuinim
slojcvima koricksa, a pokazujc znakovii visoki signal na 11-
mjcrcnim i ILA!R snimkama, sio sc ponckau pogrcsno
iumaci kao pourucjc krvarcnja. Vcnski infarkii su najccsc
izazvani irombozom vcnskih sinusa, sio sc obicno lako ui-
jagnosiicira MR!-om. Ovi infarkii nc ougovaraju aricrijskim
opskrbnim pourucjima, a ccsio su hcmoragijski, obosirani
i smjcsicni subkoriikalno.
As opposcu io C1, mosi paiicnis wiih an MCA sirokc
havc posiiivc finuings on MR! wiihin ihc firsi 24 hours.
Coriical cucma, loss of gray maiicr/whiic maiicr uiffcrcn-
iiaiion (on 12-wcighicu, ID, anu ILA!R imagcs), hypcr-
ucnsc MCA on ILA!R imagcs, anu incrcascu conirasi
opacificaiion of ihc vcsscls in ihc infarcicu arca uuc io
slowcr flow arc iypically sccn wiihin ihc firsi fcw hours.
Diffusion-wcighicu (DW!) anu pcrfusion-wcighicu (IW!)
imaging icchnigucs proviuc scnsiiiviiics anu spccificiiics
ihai arc almosi 1007 alrcauy in ihc firsi hour of ihc sirokc
onsci.
!n ihc subacuic phasc (uay 3-21) scconuary hcmor-
rhagc occurs in approximaicly 157 of MCA sirokcs. Gyri-
form conirasi cnhanccmcni is usually mosi promincni
from ihc ihiru io scvcnih uay of ihc sirokc onsci. Wallcri-
an ucgcncraiion along ihc affccicu coriicospinal iraci may
bc visualizcu siariing from four wccks of ihc sirokc onsci.
Lnccphalomalacia is cncounicrcu in ihc chronic phasc.
!solaicu infarci in ihc icrriiory of ihc anicrior ccrcbral
aricry (ACA) is a rarc cvcni (<17), morc commonly sccn
wiih inicrnal caroiiu aricry occlusions. !i may occur as a
conscgucncc of irauma or spacc-occupying lcsions. Iosic-
rior ccrcbral aricry (ICA) infarcis may bc scconuary io
iransicniorial hcrniaiion, anu in young paiicnis may inui-
caic vasculiiis.
Basilar aricry occlusion has frcgucni faial ouicomcs,
anu is characicrizcu by infarcis scaiicrcu ihroughoui ihc
infraicniorial anu posicrior ccrcbral aricry icrriiorics.
Laminar nccrosis is a spccific cniiiy, corrcsponuing io
coriical infarcis ihai prcscrvc somc laycrs, wiih a charac-
icrisiic high signal inicnsiiy on 11-wcighicu anu ILA!R
imagcs, which may bc misinicrprcicu as arcas of hcmor-
rhagc.
Vcnous infarcis arc mosi commonly causcu by ihrom-
bosis of ihc vcnous sinuscs, which is usually rcauily iucn-
iificu on MR!. 1hcsc infarcis uo noi corrcsponu io aricri-
al icrriiorics, anu arc commonly hcmorrhagic, bilaicral, anu
subcoriical.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 35
A^GIOGRAIIY I^ TI! !IAGÔSIS OI STROK!
A^GIOGRAIIJA \ !IJAGÔSTICI MOZ!AÔG \!ARA
Branka Krisick, Goruan Sari
Dcparimcni of Rauiology, Osijck Univcrsiiy Hospiial, Osijck, Croaiia
Oujcl za rauiologiju, Klinicka bolnica Osijck, Osijck
Sirokc is a hcicrogcncous group of ccrcbrovascular
uisorucrs wiih a wiuc array of clinical manifcsiaiions. 1hc
paihology, ciiology, prognosis anu ircaimcni vary accoru-
ing io iypc of sirokc. 1hc icrm sirokc covcrs ihc follow-
ing cniiiics: ischcmic ccrcbral infarci (!C!) (-807); pri-
mary iniraccrcbral hcmorrhagc (I!CH) (-157); sub-
arachnoiu hcmorrhagc (SAH) (-57); anu vcnous ihrom-
bosis (V1) (-17).
!n ihc uiagnosis anu ihcrapy planning for sirokc pa-
iicnis, angiography plays a major rolc. 1hc firsi uscful
angiography of ccrcbral vcsscls was pcrformcu in 1927. 1hc
mcihou has improvcu wiih ihc ucvclopmcni of conirasi
mcuia (CM). 1hc firsi CM was ionic anu characicrizcu by
high osmolariiy. Currcnily uscu CM is non-ionic, isoosmo-
lar, anu wiih minor siuc cffccis. 1hc mcihou is wiucly uscu
in conncciion wiih compuicr assisiancc anu uigiializaiion
of rauiological cguipmcni, which rcuuccs ihc amouni of
CM anu rauiaiion uosc.
Dircci pcrcuiancous caroiiu angiography was for long
ihc only approach io visualizc brain aricrics. !i was associ-
aicu wiih numcrous complicaiions such as aricrial wall
uamagc, subiniimal injcciion of CM, anu iniimal lcsions.
!n ihc bcginning of ihc 1950s, iranscaihcicr angiography
was firsi mcniioncu in ihc liicraiurc. Irom laic 1970s, wiih
ihc ucvclopmcni of caihcicrs, guiuing wircs anu inirouuc-
crs, uircci punciurc has bccn losing baiilc.
Angiogruhy in Ischcnic CcrcbruI Infurct
!n spiic of ihc auvcni of ncw mcihous (CD!, MRA,
C1A), inira-aricrial angiography rcmains a uscful iool for
visualizaiion of ccrvicocranial bloou vcsscls. Aricriosclcrosis
is highly associaicu wiih !C!. During angiographic procc-
uurc of iniracranial aricrics, ii is obligaiory io visualizc
cxiracranial aricrics as wcll. 1hc aims of ccrcbral angio-
graphy in aricriosclcrosis arc: io ucicrminc ihc ucgrcc of
sicnosis; io ucmonsiraic ihc associaicu 'ianucm` lcsions
ai ihc siphon anu iniracranial branchcs; io visualizc possi-
blc collaicral circulaiion; anu io provc plaguc ulccraiion.
A sicnosis >707 is consiucrcu hcmouynamically signifi-
Mozuani uuar (MU) jc hcicrogcna skupina ccrc-
brovaskularnih porcmcaja sa sirokom klinickom slikom.
Razliciia jc paiologija, ciiologija, prognoza i lijcccnjc. Vrsic
MU su: 1. mozuani ishcmijski infarki (M!!) (-807); 2.
primarno unuiarmozuano krvarcnjc (IUMK) (-157); 3.
subarahnoiuno krvarcnjc (SAH) (-57); 4. vcnskc irom-
bozc (V1) (-17). U uijagnosiici i planiranju lijcccnja MU
angiografska uijagnosiika ima vcliku ulogu. Irva upoircb-
ljiva angiografija krvnih zila mozga ucinjcna jc 1927. go-
uinc. Mcioua jc naprcuovala s razvojcm konirasinih srcu-
siava (KS). Siara KS bila su jonska, visoko osmolarna. Su-
vrcmcna su ncjonska, izoosmolarna, minimalnih nuspoja-
va. Rasircnosii mciouc uoprinijcla jc kompjuiorizacija i
uigiializacija rauioloskc oprcmc uovouci uo znacajnog
smanjcnja u poirosnji KS, kao i smanjcnju zraccnja. Dircki-
na pcrkuiana karoiiuna angiografija uugo vrcmcna bila jc
jcuini prisiup aricrijskom siablu, s brojnim komplikacija-
ma (osiccnjc siijcnkc aricrijc, subiniimna injckcija KS,
lczijc iniimc). Ioccikom 1950.-ih iranskaicicrska an-
giografija spominjc sc u liicraiuri. Ou kasnih 1970.-ih una-
prcocnjcm kaicicra, zica vouilica i uvounica poiiskujc
uirckinu punkciju.
Angiogrufiju u MII
Usprkos novim mciouama (CD!, MRA, C1A) inirar-
icrijska angiografija osiajc pouzuana mcioua prikaza ccr-
vikokranijskog aricrijskog siabla. Aicrosklcroza jc usko
povczana s ishcmijskom bolcsu mozga. U okviru an-
giografijc inirakranijskc cirkulacijc ncophouna jc i obraua
cksirakranijskog uijcla aricrija. Cilj angiografijc kou
aicrosklcrozc mozuanih aricrija jc: 1. ourcuiii siupanj
suzcnja; 2. prikazaii cvcniualnc uuruzcnc (ianucm)
lczijc u pourucju sifona i inirakranijskih ogranaka; 3. uoka-
zaii moguu kolaicralnu cirkulaciju; 4. uokazaii ulccraciju
posiojccg plaka. Suzcnjc >707 smaira sc hcmouinam-
ski znacajnim. U inirakranijskim ograncima aicrosklcroza
sc prikazujc kao ncravnosi koniura, suzcnjc aricrija, clon-
gacija i izvijuganosi, ic prisuinosi vrcicnasiih ancuriz-
maiskih prosircnja. Angiografija sc izvoui u hipcrakuinoj
36 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
fazi infarkia samo u slucaju iniraaricrijskc fibrinoliiicnc
icrapijc. Angiografski znaci akuinog infarkia su: 1. okluzi-
ja krvnc zilc; 2. usporcn proiok s prouuzcnim aricrijskim
praznjcnjcm; 3. kolaicralno, rcirograuno punjcnjc; 4. zonc
ispaua pcrfuzijc; 5. luksuzna pcrfuzija; 6. rana vcnska
urcnaza; 7. ocss--//-t uzrokovan cucmom. U kronicnom
infarkiu glavni angiografski znak jc kolaicralna cirkulacija.
Angiogrufiju u I\MK
IUMK jc najccsc aricrijskog, a rijciko vcnskog pou-
rijcila. Lokalizacija mozc biii u parcnhimu ili uz ovojnicc
mozga. Ccsio sc javlja uz iumorc, mciasiazc ili iz angio-
ma. Glavni angiografski znak jc poiiskivanjc i lucno napi-
njanjc aricrijskog i vcnskog siabla. Vrlo rijciko prikazc sc
cksiraluminacija KS. Uloga angiografijc u uijagnosiici
IUMK jc minorna nakon uvoocnja C1 i MR! kojima sc
oikriva i ciioloski cimbcnik.
Angiogrufiju u SAI
Iriblizno 907 nciraumaiskc SAH uvjciovano jc ancu-
rizmama. Mogu biii sakularnc, fuziformnc i uisccirajuc.
Angiografska slika vczana jc uz oblik. U slucaju sakularnc
ancurizmc nuzno jc uokazaii polozaj vraia raui planiranja
opcracijskog zahvaia. Nuzan jc prikaz poipunc inirakra-
nijskc cirkulacijc zbog prikaza jcunc i/ili svih ancurizama.
Lokalizacija rupiuriranc ancurizmc u slucaju nckoliko
ancurizama vczana jc za uouainc uijagnosiickc mciouc
(C1, MR).
Angiogrufiju u \T
Vcnskookluzivna bolcsi mozga jc prcrijciko uijagnos-
iiciran razlog ncuroloskog ucficiia. Iocinjc ncpoipunim
zaivaranjcm uuralnog sinusa ugruskom, a nasiavlja sc poi-
punom irombozom i sircnjcm iromba u mosnc vcnc. An-
giografski irombozirani sinus izglcua popui praznog kana-
la uz prosircnc uuralnc vcnc. 1romboziranc koriikalnc vcnc
su vrpcasic, u zraku viscc" sirukiurc. !spau prikaza vcnc
Galcni upuujc na irombozu uubokih ccrcbralnih vcna.
cani. Aricriosclcrosis of iniracranial branchcs is sccn as
irrcgulariiics of ihc coniours, clongaiion anu ioriuousiiy,
anu as fusiform ancurysms. !n ihc hypcracuic phasc of
ischcmic infarci, angiography is pcrformcu only in casc of
inira-aricrial fibrinolyiic ihcrapy. Angiographic signs of
infarciion arc: occlusion of bloou vcsscl; slow bloou flow
wiih prolongcu aricrial phasc; collaicral, rcirograuc filling;
zoncs of poor pcrfusion; luxury pcrfusion; carly vcnous
urainagc; anu cucma inuuccu mass-cffcci. Collaicral cir-
culaiion is a major angiographic sign in chronic infarciion.
Angiogruhy in Irinury IntruccrcbruI Icnorrhugc
1hc mosi common causc of I!CH is aricrial, anu in rarc
cascs vcnous blccuing. Blccuing localizaiions arc in ihc
parcnchyma or ncar mcningcs. !i is vcry common in iu-
mors, mciasiascs anu angioma. 1hc main angiographic sign
of blccuing is uisplaccmcni anu bowing of aricrial anu
vcnous branchcs. !i is uncommon io visualizc cxiralumi-
naiion of CM. 1hc rolc of angiography in I!CH uiagnosis
is minor aficr ihc invcniion of C1 anu MR!, which can
cvcn ucicci ihc ciiology of blccuing.
Angiogruhy in Suburuchnoid Icnorrhugc
Ncarly 907 of noniraumaiic SAH arc causcu by rup-
iurcu ancurysms. Ancurysms can bc saccular, fusiform anu
uisscciing. 1hc angiographic piciurc is rclaicu io ihc
shapc. !n casc of saccular ancurysm, ii is obligaiory io vi-
sualizc ihc ncck for ihc opcraiivc proccuurc planning. 1hc
cniirc iniracranial circulaiion musi bc cxamincu io show
onc or all ancurysms. !n casc of muliiplc ancurysms, ihc
localizaiion of rupiurc shoulu bc vcrificu by auuiiional
ncuroimaging mcihous (C1, MR!).
Angiogruhy in \cnous Thronbosis
V1 of ihc brain is ihc mosi unucruiagnoscu causc of
ncurologic ucficii. V1 bcgins wiih incomplcic occlusion
of uural sinuscs by a cloi anu coniinucs wiih complcic si-
nus ihrombosis anu propagaiion of ihrombosis io ihc briug-
ing vcins. On angiography, V1 appcars likc an cmpiy ca-
nal wiih uilaiaiion of uural vcins. 1hrombosis of coriical
vcins looks likc corulikc conirasi collcciions 'hanging in
spacc`. 1hc lack of CM filling of ihc Galcni vcin inuicaics
ihrombosis of uccp ccrcbral vcins.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 37
TI! ROI! OI \ITRASO\^! I^ TI! !IAGÔSIS
OI C!R!HRO\ASC\IAR !ISOR!!RS
\IOGA \ITRAZ\\KA \ !IJAGÔSTICI
MOZ!AÎI KR\OZIIÎI IOR!M!CAJA
Arijana Lovrcnci-Huzjan
Sirokc ouicomc ucpcnus on cmcrgcncy managcmcni,
sirokc iypc, anu ihcrapcuiic proccuurcs. 1hc focus is sci
on ihc carly ucicciion of paiicnis wiih known risk faciors,
whcrcby ulirasounu mcihous play a major rolc. Ulirasounu
is a noninvasivc mcihou ihai can ucfinc wiih high accura-
cy ihc risk faciors for ucvclopmcni of a spccific sirokc
subiypc. By mcans of cxiracranial color Dopplcr, ihc ap-
pcarancc anu iypc of aihcrosclcroiic plagucs can bc visu-
alizcu, anu ihus also ihc ucgrcc of sicnosis anu plaguc
siabiliiy by mcans of ihrcc- anu four-uimcnsional ulira-
sounu. Oihcr iypcs of inflammaiory ncurovascular uiscas-
cs can also bc visualizcu as wcll as nonaihcrosclcroiic vas-
culopaihics anu uisscciions, which can ucvclop inucpcn-
ucnily of ihc aforcmcniioncu uiscascs. High rcsoluiion B-
mouc ulirasounu cnablcs visualizaiion of carly aihcrosclc-
rosis (caroiiu iniima-mcuia ihickncss).
By mcans of iranscranial Dopplcr anu iranscranial col-
or-coucu Dopplcr sonography, occlusivc iniracranial uis-
casc can bc localizcu. Also, hcmouynamic rcuisiribuiion
in cxiracranial occlusivc uiscasc can bc asscsscu, anu rc-
canalizaiion of ihc occluucu vcsscl can bc obscrvcu. !n
hcmorrhagic sirokcs, suspicion of vascular malformaiions
wiih fragilc vcsscls anu blccuing inio ihc iniraccrcbral anu
subarachnoiual spacc can bc sci. 1hc iimc coursc anu
ihcrapy can bc moniiorcu. 1hc ucvclopmcni of sofiwarcs
has lcu io a wiuc variciy of applicaiions. High inicnsiiy
iransicni signals (H!1S) can bc uciccicu as a risk for
cmbolizaiion in caruiac uiscascs (lcfi airium ihrombus,
paicni foramcn ovalc) anu vascular uiscascs (unsiablc ca-
roiiu sicnosis, aoriic arch, uisscciion). 1hc possibiliiy of
vasorcaciiviiy icsiing cnablcs cvaluaiion of ihc vasomoior
capaciiy. 1hc ucvclopmcni of ulirasonographic icchnigucs
has lcu io casy anu noninvasivc asscssmcni of inuiviuuals
ai a risk of sirokc.
!shou mozuanog uuara ovisi o hiinosii zbrinjavanja, iipu
mozuanog uuara, kao i o icrapijskim posiupcima. Sioga sc
iczisic posiavlja na rano oikrivanjc bolcsnika s cimbcnici-
ma rizika za njcgov nasianak. 1u imaju vaznu ulogu ulira-
zvucnc mciouc. Ulirazvucnc mciouc su ncinvazinc mcio-
uc kojima sc mogu usianoviii cimbcnici rizika za razvoj
pojcuinoga pouiipa mozuanog uuara. Lksirakranijskim
obojcnim uoplcrom mozc sc usianoviii izglcu i vrsia aic-
ro-sklcroiskih plakova, povrsina i siupanj sicnozc zilc, ic
siabilnosi plaka upoircbom iro- i ccivcrouimcnzionalnog
ulirazvuka. Irikazuju sc urugc upalnc bolcsii krvozilja,
ncaicrosklcroiskc vaskulopaiijc i uisckcijc zila kojc sc mogu
javiii ncvczano uz ncku ou prijc navcucnih bolcsii. Visoko-
rczoluini B-mou ulirazvuk pruza uouainc informacijc o
poccinim aicrosklcroiskim promjcnama (ucbljina iniimc
i mcuijc siijcnkc karoiiunc aricrijc). 1ranskranijskim
uoplcrom i iranskranijskim obojcnim uoplcrom sc mozc
lociraii mjcsio okluzivnc promjcnc, usianoviii prcraspo-
ujcla hcmouinamikc kou cksirakranijskih okluzivnih pro-
mjcna i praiiii rckanalizaciju okluuiranc aricrijc. Kou
hcmoragijskih mozuanih uuara posiavlja sc sumnja na pos-
iojanjc krvozilnih ivorbi kou kojih nasiajc pucanjc zila i
krvarcnjc u iniraccrcbralni i subarahnoiuni prosior, ic pra-
ii razvoj i lijcccnjc. Razvoj programa uovco jc uo mogunosii
moniioriranja cmbolijskih signala kao rizika za cmboliza-
ciju kou karuijalnih bolcsii (iromb lijcvog airija, posioja-
njc oivorcnog foramcn ovalc), ic bolcsii krvozilja (sicnozc
ncsiabilnim plakovima karoiiunih aricrija, luka aoric, ui-
sckcijc isiih zila). Moguc jc icsiiranjc vazorcakiivnosii u
procjcni vazomoiornog kapaciicia. Razvoj ulirazvucnih ic-
hnika uovco jc uo olaksanc i ncinvazivnc procjcnc ispiia-
nika s rizikom za nasianak mozuanog uuara.
38 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
Main 1opic V V. glavna icma
1HLkAl Cl S1kClL
1LkAll}A MCZDANCC UDAkA
TR!ATM!^T OI AC\T! STROK!
T!RAIIJA AK\TÔG MOZ!AÔG \!ARA
Vcsna Vargck-Solicr
Klinika za ncurologiju, Klinicka bolnica ,Scsirc milosrunicc,
1hc main goal of ircaimcni is io lcsscn ihc brain uam-
agc uuc io ischcmia anu ihc ncurologic ucficii uuc io
sirokc. 1hc zonc cncircling ihc ischcmic pari wiih pariial
uisiurbancc of cncrgy capaciiy is callcu pcnumbra. Mosi
imporiani is io siari ihc ircaimcni as carly as possiblc in
spccializcu inicnsivc carc uniis (!CU), wiihin 3 io 6 hours
from ihc onsci of uiscasc. 1hc main aim is io confirm ihc
uiagnosis anu cxcluuc ihc siaics ihai can show ihc fcaiurcs
of sirokc, whcrc ihc usc of spccific ircaimcni can cvcn
worscn ihc ouicomc. 1hc currcni ircaimcni for ischcmic
sirokc is limiicu io a small numbcr of spccific ihcrapcuiic
proccuurcs anu a vcry narrow iimc framc. Siill many mcu-
icaiions arc uscu uuc io crroncous bclicf ihai ihcy arc cf-
fcciivc anu safc for ihc paiicni. All prcscni knowlcugc
iakcs as an impcraiivc ihc carly bcginning of ircaimcni,
imposing ihc nccu of a highly imporiani iask of cuucaiing
boih hcalih pcrsonncl anu ihc populaiion ai largc.
Smanjiii osiccnjc mozga zbog ishcmijc i ncuroloskog
ucficiia kao posljcuicc mozuanog uuara osnovni jc cilj
lijcccnja. Zona koja okruzujc srcuisnji uio ishcmijc u kojoj
jc prisuian ujclomican porcmcaj cncrgciskog kapaciicia
naziva sc pcnumbrom. Najvaznijc jc poccii lijcccnjc sio
ranijc u spccijaliziranim jcuinicama inicnzivnog lijcccnja
(]!L), i io unuiar 3 uo 6 saii ou poccika bolcsii. Osnovno
jc poivruiii uijagnozu ic iskljuciii sianja koja mogu poka-
zivaii klinicku sliku mozuanog uuara u kojima primjcna
spccificnog lijcccnja mozc i pogorsaii ishou. Sauasnjc
lijcccnjc akuinog ishcmijskog uuara ograniccno jc na malcn
izbor spccificnc icrapijc i vrlo uzak vrcmcnski prozor. ]os
uvijck sc mnogi lijckovi ruiinski primjcnjuju u pogrcsnom
vjcrovanju ua su ujcloivorni i sigurni za bolcsnika. Sva uosa-
uasnja saznanja uvouc kao impcraiiv sio raniji pocciak
lijcccnja, a io kao najvazniji zauaiak namcc obrazovanjc
kako zuravsivcnog osoblja iako i sirc javnosii.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 39
^!\ROS\RGICAI MAÂG!M!^T OI I^TRACRAÎAI
A^!\RYSMS A^! I^TRAC!R!HRAI I!MATOMAS
^!\ROKIR\RSKO IIJ!C!^J! I^TRAKRAÎJSKII
A^!\RIZAMA I I^TRAC!R!HRAIÎI I!MATOMA
Vclimir Luprci, Vili Bcros
Univcrsiiy Dcparimcni of Ncurosurgcry, Scsirc milosrunicc Univcrsiiy Hospiial, Zagrcb, Croaiia
Klinika za ncurokirurgiju, Klinicka bolnica Scsirc milosrunicc", Zagrcb
!niracranial ancurysms anu iniraccrcbral hcmaiomas
arc ihc mosi common rcason for ncurosurgical managc-
mcni of ccrcbrovascular uisorucrs. !niracranial ancurysms
arc baggy-likc, saccular, clongaicu, fusiform or uisscciing
lcsions of ihc wall of ccrcbral vcsscls, which arc causcu by
ciihcr siruciural changcs of ihc vcsscl wall or by hcmouy-
namic faciors. Rupiurc of iniracranial ancurysms causcs
subarachnoiu hcmorrhagc, an cmcrgcncy clinical siaic
characicrizcu by spccific clinical manifcsiaiions.
Aficr ihc iniiial cvcni, hcmorrhagc inio ihc subarach-
noiu spacc, a paihophysiologic scgucncc of cvcnis will
occur ihai arc rcsponsiblc for ihc clinical piciurc anu uc-
icrminc ihc ouicomc of ihc paihologic cvcni. Iaiicnis wiih
subarachnoiu hcmorrhagc arc cnuangcrcu noi only by ihc
iniiial hcmorrhagc bui also by iis complicaiions such as
rchcmorrhagc, vasospasm anu hyuroccphalus.
1hc mosi imporiani gucsiion in ircaiing ihc paiicni
wiih subarachnoiu hcmorrhagc, from ihc ncurosurgical
poini of vicw, is whcn io opcraic. 1hc answcr is almosi
ncvcr unambiguous anu is influcnccu by scvcrcal faciors.
Iaciors ihai arc analyzcu whcn making ihc uccision on
iiming of opcraiion arc: possibiliiy of rchcmorrhagc, prcs-
cncc of vasospasm anu possibiliiy of iis cvoluiion, paiicni`s
clinical siaic, amouni of bloou in ihc subarachnoiu spacc
vcrificu by C1 scan, agc of paiicni, associaicu conuiiions,
brain iissuc cucma vcrificu by C1 scan, localizaiion anu
shapc of ancurysm, prcscncc of iniraparcnchymal blccu-
ing or oihcr complicaiions, opcraiing icam cxpcricncc, anu
finally ihc iimc ihai has clapscu from ihc onsci of sub-
arachnoiu hcmorrhagc io hospiial aumission.
Consiucring all ihcsc as wcll as our own 22-ycar clini-
cal cxpcricncc anu a scrics of 932 iniracranial ancurysms
opcraicu on, wc havc camc io somc conclusions ihai arc
claboraicu in ihc guiuclincs for ihc managcmcni of such
lcsions (guiuclincs for opcraiivc ircaimcni of paiicnis wiih
subarachnoiu hcmorrhagc causcu by rupiurc of iniracra-
nial ancurysm).
Najccsi supsirai ncurokirurskog lijcccnja ccrcbro-
vaskularnih porcmcaja su inirakranijskc ancurizmc i in-
iraccrcbralni hcmaiomi. !nirakranijskc ancurizmc su vrc-
asic - sakularnc, izuuzcnc - fuziformnc ili uisccirajuc pro-
mjcnc na siijcnkama ccrcbralnih krvnih zila, kojc su uzro-
kovanc bilo sirukiurnim promjcnama samc siijcnkc krvnih
zila bilo hcmouinamskim cimbcnicima. Rupiura inirak-
ranijskih ancurizama uzrokujc subarahnoiuno krvarcnjc,
hiino klinicko sianjc obiljczcno spccificnim klinickim po-
javnosiima. Nakon poccinog zbivanja, krvarcnja u subarah-
noiuni prosior, slijcui ciiav niz paiofizioloskih zbivanja koja
uzrokuju klinicku sliku i ourcouju ishou paioloskog zbiva-
nja. Bolcsnici sa subarahnoiunim krvarcnjcm paiofiziolo-
ski su ugrozcni kako samim poccinim krvarcnjcm iako i
njcnim komplikacijama kao sio su ponovljcno krvarcnjc, va-
zospazam i hiuroccfalus. S ncurokirurskog siajalisia, u
lijcccnju bolcsnika sa subarahnoiunim krvarcnjcm naj-
vaznijc jc piianjc kaua iakvog bolcsnika opcriraii. Ougo-
vor goiovo nikaua nijc jcunoznacan, a na njcga uijccu broj-
ni cimbcnici. Cimbcnici kojc analiziramo pri uonoscnju
oulukc o vrcmcnu opcracijc su sljcuci: mogunosi ponov-
ljcnog krvarcnja, prisuinosi vazospazma, kao i mogunosi
njcgova razvoja, bolcsnikovo klinicko sianjc, kolicina krvi
u subarahnoiunim prosiorima uokazana C1 snimanjcm,
bolcsnikova uob, posiojcc bolcsii, cucm mozuanog ikiva
uokazan C1 snimanjcm, zaiim lokalizacija i oblik samc
ancurizmaiskc ivorbc, prisuinosi iniraparcnhimnog
krvarcnja ili urugih komplikacija, iskusivo opcracijskog iima
i na kraju vrijcmc kojc jc proicklo ou napauaja subarah-
noiunc hcmoragijc uo prijma bolcsnika. Uzimajui u obzir
navcucno, kao i nasc vlasiiio 22-gouisnjc iskusivo uz 932
opcriranc inirakranijskc ancurizmc uosli smo uo zakljuca-
ka koji su izncscni u smjcrnicama za lijcccnjc ovih ivorbi
(smjcrnicc za opcracijsko lijcccnjc bolcsnika sa subarah-
noiunim krvarcnjcm uzrokovanim rupiurom inirakranijskc
ancurizmc). Iraici najnovijc ircnuovc u lijcccnju inira-
kranijskih ancurizama, u suraunji s ncurorauiolozima Kli-
40 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
nickoga zavoua za rauiologiju nasc bolnicc uvcli smo u nasu
sianuarunu klinicku praksu i inicrvcninc - cnuovaskularnc
mciouc lijcccnja ovih ivorba. Naimc, razvojcm ichnologijc
posiupno sc razvijaju novc ichnikc sclckiivnc cnuovasku-
larnc obliicracijc samih ancurizmaiskih ivorba mciouom
njihovog punjcnja razliciiim maicrijalima - najccsc za-
vojnicama (o//s) - uz ocuvanjc krvnog proioka u glavnoj
aricriji na kojoj sc ancurizma razvija. U poccinom razuob-
lju primjcnc cnuovaskularnih ichnika lijcccnja ovc mciouc
bilc su rczcrviranc za bolcsnikc kou kojih jc ncurokirurski
rizik bio vclik, sioga sc pribjcgavalo urugim icrapijskim
opcijama. 1ako su u poccinoj fazi najccsi kanuiuaii za
cnuovaskularni posiupak bili bolcsnici loscg klinickog sia-
nja, visokc siarosnc uobi ic oni s vrlo icskim lokalizacija-
ma ancurizmaiskc ivorbc, uaklc, svi oni bolcsnici kou kojih
opcracijska mcioua nijc bila mcioua prvoga izbora. Raz-
vojcm ichnologijc ic procjcnom poccinih rczuliaia uviu-
jclo sc ua cnuovaskularni zahvaii imaju i ourcocnc prcu-
nosii nau opcracijskim zahvaiima. Sioga uanas ovaj posiu-
pak, ako sc za njcga posiavi inuikacija, nasiavljamo oumah
nakon uijagnosiickc angiografijc i vcrifikacijc inirakranijskc
ancurizmc, ncposrcuno nakon prijma bolcsnika u bolnicu.
Iormirani ccrcbrovaskularni iim sio ga cinc ncurokirurg,
inicrvcnini ncurorauiolog ic ancsicziolog, nakon posiav-
ljanja uijagnozc i uokazivanja ancurizmc, uonosi ouluku o
nacinu lijcccnja procjcnjujui ourcocnc paramcirc, ic sc
uonosi ouluka o ualjnjim posiupcima, ounosno nacinu
lijcccnja. Misljcnja smo ua jc ovakav, muliiuiscipinarni
nacin saglcuavanja paioloskog supsiraia i planiranja ic-
rapijskih opcija jcuini ispravan nacin lijcccnja iako za-
hijcvnih" bolcsnika. Sio sc ncurokirurskog lijcccnja spon-
ianih iniraccrcbralnih hcmaioma iicc, smjcrnicc su raz-
mjcrno prcciznc. !niraccrcbralnc hcmaiomc iako uijclimo
s obzirom na vclicinu i lokalizaciju, ic nacclno mozcmo rci
sljcucc:
hcmaiomc siraznjc lubanjskc jamc i malog mozga po-
ircbno jc opcracijski (hiino) lijcciii;
opcracijski mozcmo lijcciii bolcsnikc s hcmaiomima
vclicinc ou 47 uo 12 7 hcmisfcrc (lobarni hcmaiomi)
cijc jc klinicko sianjc u pogorsanju;
opcracijsko i konzcrvaiivno lijcccnjc uaju poujcunako
losc rczuliaic u lijcccnju bolcsnika s hcmaiomima
vclicinc prcko 12 7 hcmisfcrc vclikog mozga;
konzcrvaiivno lijccimo bolcsnikc s hcmaiomima
vclicinc ou 17 uo 4 7 lokaliziranc u bazalnim gangliji-
ma, ialamusu i kapsuli inicrni.
U posljcunjc vrijcmc iniraccrcbralnc hcmaiomc lijcci-
mo i cnuoskopski, ij. uz pomo ncurorauioloskih mcioua,
izv. op-r MR css/st-d r-eroser-ry".
Iollowing rcccni ircnus in ihc managcmcni of inira-
cranial ancurysms, in coopcraiion wiih ncurorauiologisis
from ihc Dcparimcni of Rauiology of our hospiial, wc havc
inirouuccu inicrvcniional-cnuovascular mcihous in ihc
ircaimcni of such lcsions in our sianuaru clinical praciicc.
Grauually, wiih icchnology ucvclopmcni, ncw icchnigucs
of sclcciivc cnuovascular obliicraiion of ancurysms by fill-
ing ihcir lumcn wiih various maicrials, usually 'coils`, ihcrc-
by prcscrving bloou flow in ihc aricry whcrc ihc ancurysm
is ucvcloping, havc bccomc availablc. 1hc iniiial pcriou of
ihc usc of cnuovascular icchnigucs was rcscrvcu for pa-
iicnis ai a grcaicr risk for opcn surgcry, ihcrcforc oihcr
ircaimcni opiions wcrc consiucrcu. !n ihis phasc, canui-
uaics for cnuovascular ircaimcni wcrc mosily paiicnis
wiih worsc clinical siaic, olucr agc, anu uifficuli localiza-
iion of ancurysm; in shori, paiicnis in whom opcn surgcry
was noi ihc firsi choicc mcihou of ircaimcni.
Wiih icchnology ucvclopmcni anu cvaluaiion of iniiial
rcsulis, somc auvaniagcs of cnuovascular ircaimcni ovcr
opcn surgcry havc bccn csiablishcu. 1hcrcforc, if ihcrc is
inuicaiion, ihc proccuurc will bc pcrformcu immcuiaicly
upon uiagnosiic angiography anu vcrificaiion of iniracra-
nial ancurysm.
1hc ccrcbrovascular icam consisis of a ncurosurgcon,
an inicrvcniional rauiologisi anu an ancsihcsiologisi. Whcn
ihc uiagnosis is mauc, ihc icam ucciucs on ihc ircaimcni
opiions by cvaluaiing pariicular paramcicrs, anu furihcr
proccuurcs anu ircaimcni opiions arc uiscusscu.
Wc ihink ihai such a muliiuisciplinary approach in ihc
analysis of ihc paihologic subsiraic anu planning of ircai-
mcni opiions is ihc only righi approach in ihc managcmcni
of ihis challcnging conuiiion.
Conccrning ihc ncurosurgical ircaimcni of sponianc-
ous iniraccrcbral hcmaiomas, ihc guiuclincs arc prccisc.
!niraccrcbral hcmaiomas arc uiviucu accoruing io ihcir
volumc anu localizaiion. So wc can siaic ihc following:
hcmaiomas in ihc posicrior fossa anu ccrcbcllum arc
ihc conuiiions ihai rcguirc cmcrgcncy surgical ircai-
mcni,
paiicnis wiih hcmaiomas ihai occupy 47 io 127 of ihc
brain hcmisphcrc (lobar hcmaioma) anu ihcir clinical
piciurc is worscning can bc opcraiivcly ircaicu,
comparably, poor rcsulis arc obiaincu by opcraiivc anu
conscrvaiivc ircaimcni of hcmaiomas wiih a volumc
cxcccuing 127 of ihc hcmisphcrc, anu
paiicnis wiih hcmaiomas of a volumc of 17 io 4 7 anu
arc localizcu in basal ganglia, ihalamus anu capsula
inicrna, arc conscrvaiivcly ircaicu.
Rcccnily, iniraccrcbral hcmaiomas arc also ircaicu
cnuoscopically or by using ncurorauiologic mcihous, so-
callcu 'opcn MR assisicu ncurosurgcry`.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 41
A^TICOAG\IA^T TI!RAIY I^ TI! IR!\!^TIO^
A^! TR!ATM!^T OI STROK!
A^TIKOAG\IA^TÂ T!RAIIJA \ IR!\!^CIJI I IIJ!C!^J\
MOZ!AÔG \!ARA
Branko Rauanovi, Bahrija Lcnz
Aniikoagulacijc sc u praksi primjcnjuju vc niz gouina
i prcusiavljaju prcumci brojnih rasprava. U 807 slucajcva
mozuanog uuara (MU) nalazc sc ishcmijski uogaoaji zbog
okluzijc krvnc zilc. Aniiiromboisko lijcccnjc ounosi sc prijc
svcga na ishcmijski MU, ali jc rizik ou inirakranijskog
krvarcnja osnovna prcprcka uporabi aniiiromboiskih lijc-
kova kako u prcvcnciji MU iako i lijcccnju bolcsnika s MU.
Aniiiromboiska icrapija ima icmcljnu ulogu u prcvcnciji
ishcmijskog MU. Najvci jc rizik s iromboliiicima, ncsio
manji s aniikoakulansima i najmanji, ali ipak posioji s anii-
irombociinim lijckovima. Lijcccnjc vaskularnih rizicnih
cimbcnika kao sio su hipcricnzija, puscnjc, uijabcics i hi-
pcrlipiucmija, i uporaba aniiiromboiskih lijckova uva su
glavna prisiupa prcvcnciji primarnog i sckunuarnog MU.
Kou primjcnc aniiiromboiskog lijcccnja u prcvcnciji MU
ircba razlikovaii ousuinosi karuiogcnog cmbolizma ou kar-
uiocmbolijskog MU. U primarnoj prcvcnciji kou nckaruio-
gcnog cmbolizma na prvom mjcsiu ou lijckova jc aspirin
koji jc i jcuino prouccn u primarnoj prcvcnciji. Iokazalo sc
ua jc razumno primijcniiii aspirin kou aicromskih bolcsnika
(asimpiomaiska sicnoza karoiiua) i onih s vcim rizikom
infarkia miokarua i srcanc smrii ncgoli infarkia mozga. Sc-
kunuarna prcvcncija prijc svcga obuhvaa bolcsnikc koji su
imali prvu iranziiornu ishcmijsku aiaku (1!A) ili MU i pou
vclikim su rizikom ou bilo kojcg vakularnog uogaoanja,
najccsc urugog MU ili infarkia srca. Osiaju oivorcna brojna
piianja koja ukljucuju opiimalnc uozc aspirina, izbor naj-
boljcg aniiiromboiskog lijcka ili kombinacija lijckova i
ucinkoviiosi novih aniiiromboiskih lijckova kao sio su
aniaganosii GI !!b/!!!a. Ou urugih aniiiromboiskih lijc-
kova primjcnjuju sc iiklopiuin, klopiuogrcl i uipiriuamol.
Dok nc buuc jos pouaiaka o ucinkoviiosii i sigurnosii
primjcnc aniikoagulanaia, aniiirombociini lijckovi osiaju
lijck izbora u prcvcnciji aicroiromboiskog MU ounosno u
bolcsnika bcz srcanog izvora cmbolizma. Ircvcncija karui-
ocmbolijskog MU icmclji sc prvcnsivcno na spccificnom
lijcccnju srcanc bolcsii i uporabi oralnih aniikoagulanaia.
Aniicoagulani agcnis ihai arc uscu in praciicc for ycars,
havc bccn ihc subjcci of many uiscussions. !n 807 of sirokc
cascs, ihc unucrlying causcs arc ischcmic cvcnis uuc io
vascular occlusion. Aniiihromboiic ihcrapy primarily rcfcrs
io ischcmic sirokc, howcvcr, ihc risk of iniracranial hcm-
orrhagc is ihc main hinurancc io ihc usc of aniiihromboiic
urugs in boih ihc prcvcniion anu ircaimcni of sirokc.
Aniiihromboiic ihcrapy has ihc crucial rolc in ihc prcvcn-
iion of ischcmic sirokc. 1hc highcsi risk is associaicu wiih
ihc usc of ihrombolyiics. 1hc risk is lcss pronounccu wiih
aniicoagulanis, anu is ihc lcasi alihough siill prcscni wiih
aniiplaiclci agcnis. 1hc ircaimcni of vascular risk faciors
such as hypcricnsion, cigarciic smoking, uiabcics mclli-
ius anu hypcrlipiucmia, anu ihc usc of aniiihromboiic
agcnis arc ihc iwo main approachcs in ihc prcvcniion of
primary anu scconuary sirokc. !n ihc usc of aniiihromboiic
ihcrapy for prcvcniion of sirokc, ihc abscncc of caruiogcnic
cmbolism shoulu bc uiffcrcniiaicu from caruiocmbolic
sirokc. !n primary prcvcniion in noncaruiogcnic cmoblism,
aspirin is ihc firsi choicc urug, as ii is ihc only urug ihai
has bccn siuuicu in primary prcvcniion. 1hc usc of aspi-
rin has provcu rcasonablc in paiicnis wiih aihcromas (as-
ympiomaiic caroiiu sicnosis) who arc ai a highcr risk of
myocaruial infarciion anu caruiac ucaih ihan of brain inf-
arciion. Scconuary prcvcniion primarily incluucs paiicnis
who havc suffcrcu firsi cvcr iransicni ischcmic aiiack
(1!A) or sirokc anu arc ai a high risk of any vascular cvcni,
mosily scconu sirokc or myocaruial infarciion. Many gucs-
iions rcmain opcn in ihc ficlu, c.g., opiimal aspirin uoscs,
choicc of ihc mosi appropriaic aniiihromboiic agcni or a
combinaiion of agcnis, anu cfficacy of novcl aniiihromboiic
urugs such as GI !!b/!!!a aniagonisis. Oihcr aniiihrom-
boiic urugs in usc arc iiclopiuin, clopiuogrcl anu uipy-
riuamolc. Uniil morc uaia on ihc cfficacy anu safciy of
aniicoagulanis bccomc availablc, aniiplaiclci urugs rcmain
ihc urugs of choicc in ihc prcvcniion of aihcroihromboiic
sirokc anu in paiicnis wiihoui ihc caruiac origin of cmbo-
42 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
Ovo sc ounosi na svc visoko rizicnc izvorc karuijalnog cm-
bolizma (miiralna sicnoza, mchanickc umjcinc valvulc, nc-
uavni infarki srca, muralna iromboza lijcvc klijcikc, airij-
ska fibrilacija). Airijska fibrilacija jc i najccsi izvor karui-
jalnog cmbolizma i ougovorna ja za oko 507 svih cmbolusa
srca. Kou airijskc fibrilacijc oralni aniikoagulansi su lijck
izbora. !sirazivanja su pokazala ua su aspirin i oralni anii-
koagulansi ucinkoviii u primarnoj i sckunuarnoj prcvcnciji
ishcmijskog MU u bolcsnika s airijskom fibrilacijom, ali su
oralni aniikoagulansi uuruzcni s vcim rizikom krvarcnja.
Kou primjcnc lijcka uvijck ircba u svakom pojcuinom sluca-
ju procijcniii piianjc rizika cmbolijskog MU i rizika op-
scznijcg krvarcnja. Kou osialih srcanih bolcsii aniiirom-
boiska siraicgija prcvcncijc MU icmclji sc na nacclu ba-
lansiranja rizika i cmbolijc. Ouluka o primjcni aniiirom-
boiskc icrapijc sc mora uonijcii na icmclju svakog pojcui-
nacnog slucaja vazui rizik ranc pojavc novih cmbolusa s
rizikom iniraccrcbralnog krvarcnja kojc najvisc ovisi o
vclicini infarkia. U aniiiromboiskom lijcccnju akuinog
ishcmijskog MU u uporabi su aniiiromboiski lijckovi, an-
iikoagulansi, iromboliiici i lijckovi koji smanjuju fibrino-
gcn. Nasuproi prcvcnciji gujc posioji opc mcounarouno
slaganjc glcuc lijcccnja akuinog ishcmijskog inzulia, pos-
iojc vaznc razlikc u aniiiromboiskoj siraicgiji. Niz ispiii-
vanja uosau jc pokazao ua jc aspirin jcuini aniiirombociini
lijck koji jc procijcnjcn u lijcccnju akuinog ishcmijskog
MU. Ou novijih aniiirombociinih lijckova u lijcccnju akui-
nog ishcmijskog MU, koji su jos u ispiiivanju, mogu sc
spomcnuii aniagonisii rcccpiora GI !!b/!!!a. Ou aniiko-
agulanaia u primjcni su razliciii hcparini: ncfrakcionirani
hcparin, hcparin niskc molckurarnc iczinc (LMWH) i
hcparinoiu (Organon). Iokazalo sc ua niskc uozc hcpari-
na, i io niskomolckularnog, ircba rabiii u bolcsnika s hcmi-
plcgijom i ograniccnom pokrciljivosii u prcvcnciji uubokc
vcnskc irombozc i plunc cmbolijc. 1romboliza jc u MU
rcvolucija, jcr jc pokazala kako jc biian cilj oporavka hiino
usposiavljanjc iijcka krvi. U uporabi su sircopiokinaza,
iniravcnski rckombinacijski akiivaior ikivnog plazminogc-
na (!V ri-IA), iniraaricrijska prourokinaza. !niraaricrijska
prourokinaza (!A) alicrnaiiva jc iniravcnskoj irombolizi, no
poircban jc angiogram mozga kako bi sc ourcuilo mjcsio
okluzijc ic kako bi sc srcusivo uoprcmilo u ugrusak. U
novijc vrijcmc u ispiiivanju jc Ancrou, proicaza zmijc, srcu-
sivo kojc razgraoujc fibrinogcn. Aniiiromboiska sircicgi-
ja akuinog lijcccnja ishcmijskog MU razlikujc sc ovisno o
uosiupnosii ri-Ia. U zcmljama u kojima nijc ouobrcn ili
nakon visc ou 3 saia aspirin jc lijck izbora uuruzcn s niskim
uozama LMWH uvijck kaua posioji hcmiplcgija ili og-
raniccna pokrciljivosi (zbog prcvcncijc uubokc vcnskc
irombozc i plunc cmbolijc).
lism. 1hc prcvcniion of caruiocmbolic sirokc is primarily
bascu on ihc spccific ircaimcni of caruiac uiscasc anu
auminisiraiion of oral aniicoagulanis. 1his rcfcrs io all high
risk origins of caruiac cmbolism (miiral sicnosis, mcchan-
ical ariificial valvcs, rcccni myocaruial infarciion, mural
ihrombosis of ihc lcfi vcniriclc, airial fibrillaiion). Airial
fibrillaiion is ihc mosi common origin of caruiac cmbolism
anu is rcsponsiblc for somc 507 of all caruiac cmboli. !n
airial fibrillaiion, oral aniicoagulanis arc ihc urugs of choicc.
Siuuics havc shown ihai aspirin anu oral aniicoagulanis arc
cfficacious in ihc primary anu scconuary sirokc prcvcniion
in paiicnis wiih airial fibrillaiion, howcvcr, oral aniicoag-
ulanis arc associaicu wiih a highcr risk of hcmorrhagc. On
prcscribing ihc urug, asscssmcni of ihc risk of cmbolic
sirokc anu of massivc hcmorrhagc shoulu always bc inui-
viuualizcu. !n oihcr caruiac uiscascs, ihc aniiihromboiic
siraicgy of sirokc prcvcniion is bascu on ihc principlc of
balancing ihc risk anu cmbolism. 1hc uccision on ihc
auminisiraiion of aniiihromboiic ihcrapy shoulu bc mauc
inuiviuually for cach casc, wcighing ihc risk of carly occur-
rcncc of ncw cmboli anu of iniraccrcbral hcmorrhagc,
which mosily ucpcnus on ihc sizc of infarci. !n ihc anii-
ihromboiic ircaimcni of acuic ischcmic sirokc, aniiihrom-
boiic urugs, aniicoagulanis, ihrombolyiics anu fibrinogcn
rcuucing agcnis havc bccn uscu. !n conirasi io prcvcniion,
whcrc an inicrnaiional conscnsus has bccn achicvcu, con-
siucrablc uiffcrcnccs rclaicu io aniiihromboiic siraicgy
cxisi in ihc managcmcni of acuic ischcmic sirokc. Numcr-
ous siuuics havc shown ihai aspirin is ihc only aniiplaic-
lci urug ihai has bccn cvaluaicu in ihc ircaimcni of acuic
sirokc. Of ihc ncw aniiplaiclci agcnis for ihc ircaimcni
of acuic ischcmic sirokc ihai arc currcnily unucr siuuy,
mcniion shoulu bc mauc of ihc GI !!b/!!!a rcccpior an-
iagonisis. Conccrning aniicoagulanis, various hcparins
havc bccn uscu, c.g., nonfraciionaicu hcparin, low molcc-
ular wcighi hcparin (LMWH), anu hcparinoiu (Organon).
!i has bccn shown ihai low uoscs of low molccular hcp-
arin shoulu bc uscu in paiicnis wiih hcmiplcgia anu lim-
iicu mobiliiy for ihc prcvcniion of uccp vcnous ihrombo-
sis anu pulmonary cmbolism. 1hrombolysis has broughi
rcvoluiion in ihc managcmcni of sirokc, bccausc ii has
ucmonsiraicu ihai ihc major goal of rccovcry is ihc fasi-
csi possiblc rcsiiiuiion of bloou flow. Sircpiokinasc, inira-
vcnous rccombinani iissuc plasminogcn aciivaior (!V ri-
IA), anu inira-aricrial prourokinasc arc bcing uscu. !nira-
aricrial prourokinasc (!A) is an alicrnaiivc io iniravcnous
ihrombolysis, howcvcr, ccrcbral angiogram is rcguircu io
iucniify ihc siic of occlusion anu io allow for ihc agcni io
rcach ihc cloi. Rcccnily, Ancrou, a vipcr vcnom proicasc,
a fibrinogcn ucgrauing agcni, has also bccn invcsiigaicu.
1hc aniiihromboiic siraicgy in ihc managcmcni of acuic
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 43
\ASC\IAR S\RG!RY I^ STROK! TI!RAIY
\ASK\IARÂ KIR\RGIJA \ T!RAIIJI MOZ!AÔG \!ARA
1omislav Sosa
Univcrsiiy Dcparimcni of Surgcry, Mcrkur Univcrsiiy Hospiial, Zagrcb, Croaiia
Klinika za kirurgiju, Klinicka bolnica ,Mcrkur, Zagrcb
ischcmic sirokc uiffcrs accoruing io ri-IA availabiliiy. !n
ihc counirics whcrc ri-IA has noi bccn approvcu, or aficr
3 hours of sirokc onsci, aspirin in combinaiion wiih low
uoscs of LMWH is ihc ihcrapy of choicc in casc of hcmi-
plcgia or limiicu mobiliiy (for ihc prcvcniion of uccp
vcnous ihrombosis anu pulmonary cmbolism).
Caroiiu surgcry is noi jusi an organ surgcry. !i is a sur-
gcry of ihc soul anu pcrsonaliiy which grcaily influcnccs
ihc paiicni`s gualiiy of lifc. 1oial cosi of sirokc in ihc
Rcpublic of Croaiia is 120.000.000 USD p-r ycar. 1hc high
ncurologic morbiuiiy, morialiiy anu social implicaiions
poini io ihc imporiancc of ihc rccogniiion anu ircaimcni
of caroiiu uiscasc in orucr io rcuucc ihc raics of sirokc.
Lach ycar, morc ihan 8000 inuiviuuals suffcr sirokc in
Croaiia. 1hc rcal nccus of caroiiu cnuaricrcciomy or ca-
roiiu sicniing (CLA/CAS) risc io >2500 opcraiions p-r
ycar. CLA shoulu bc a safc opcraiion, wiih ihc proporiion
of sirokc anu ucaih in ihc rcsulis of 0.57 - 2.57. 1hc iso-
laicu proccuurc rclaicu ucaih raic shoulu bc lcss ihan 17.
!i sccms ihai locorcgional ancsihcsia is mosi rcliablc in
rcvcaling pcriopcraiivc ncurologic morbiuiiy anu in rcuuc-
ing ihc iimc of hospiial siay. Iollowing cnulcss uiscussions
in ihc pasi, in ihc 1990s ii was rccognizcu ihai surgcons
shoulu ircai pariicular subgroups of paiicnis raihcr ihan
uispuic whcihcr or noi io opcraic on.
Irospcciivc ranuomizcu siuuics conuucicu in ihc
1980s/1990s havc lcu io ihc nccu of achicving muliiuisci-
plinary, muliiccnicr conscnsus on surgical prcvcniion anu
managcmcni of sirokc by -viucncc /ascu ocuicinc (LBM).
Somc rcccni imporiani cvcnis havc bccn siimulaicu by a
grcai numbcr of muliiccnicr rcporis following opcraiivc
proccuurcs in asympiomaiic paiicnis, inuicaiing ihai CLA/
CAS can prcvcni ihc occurrcncc of sirokc. 1hc laicsi !n-
icrnaiional Ovcrscas Conscnsus on ihc Managcmcni of
Asympiomaiic Caroiiu Bifurcaiion Sicnosis (Marscillcs
Karoiiuna kirurgija nijc ick kirurgija organa. 1o jc kirur-
gija uusc i osobnosii koja znacajno uijccc na kvaliiciu zivoia
bolcsnika. Ukupni iroskovi mozuanog uuara u Rcpublici
Hrvaiskoj iznosc 120.000.000 USD gouisnjc. Visok ncuro-
loski morbiuiici, morialiici i urusivcnc implikacijc ukazuju
na vaznosi prcpoznavanja i lijcccnja karoiiunc bolcsii s
ciljcm smanjcnja siopc mozuanog uuara. U Hrvaiskoj svakc
gouinc >8000 bolcsnika uozivi ishcmijski mozuani uuar.
Sivarna poircba karoiiunc cnuaricrckiomijc ili karoiiunog
sicniinga (CLA/CAS) rasic uo >2500 opcracija gouisnjc.
CLA ircba biii sigurna opcracija, s uujclom mozuanog uuara
i smrii u rczuliaiima ou 0,57-2,57. !zuvojcna smrinosi
zahvaia ircbala bi biii manja ou 17. Cini sc ua lokorcgio-
nalna ancsiczija najpouzuanijc oikriva pcrioopcracijski
ncuroloski morbiuiici i skraujc vrijcmc bolnickog lijccc-
nja. Ioslijc bcskonacnih rasprava u proslosii, u ucvcucscii-
ma jc izronila spoznaja ua kirurzi ircbaju lijcciii pouskupinc
bolcsnika, a nc sporiii sc ircba li opcriraii ili nc. Irospck-
iivnc, ranuomiziranc siuuijc u `80./`90.-iim uovclc su nas
uo poircbc za muliiuisciplinarnim, muliiccniricnim kon-
scnzusima o kirurskoj prcvcnciji i lijcccnju mozuanog
uuara, mcuicinom icmcljcnom na uokazima (Ec/d-r- Bcs-d
M-d//r-). Ncuavni vazni uogaoaji poiaknuii su vclikim
brojcm muliiccniricnih izvjcsiaja nakon opcracija u asim-
piomaiskih bolcsnika. Oni ukazuju na cinjcnicu ua CLA/
CAS mogu sprjccavaii mozuani uuar. Noviji Mcounarouni
prckomorski konscnzusi o lijcccnju asimpiomaiskc
sicnozc karoiiunc bifurkacijc (Marscillcs `98., Zagrcb `00.,
Cipar `01., Lonuon `02.) napravili su znacajan korak napri-
44 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
jcu uvouci kvaliiaiivnu uz uosauasnju kvaniiiaiivnu ana-
lizu plaka. U proicklom ucsciljcu brzi razvoj ncinvazivnc
uijagnosiikc namcinuo jc ncizbjcznu rccvaluaciju aricri-
ografijc kao zlainog sianuarua". Ou 1995. kriicriji ncovisni
ou ociiavaca (ror-op-rctor d-p-rd-rt r/t-r/c) ucfinirani su u
UZV i C1 uijagnosiici. Iovjcrcnsiva za zuravsivo (H-c/t/
Ccr- Cooo/ss/ors) zapoccla su ouobravanja Ccniara izvrs-
nosii u ulirazvucnoj uijagnosiici. U 2002. gouini karoiiu-
na bolcsi uijcli sc na asimiomaisku ili simpiomaisku, po-
gounu za longiiuuinalnu CLA, pogounu za cvcrzionu cn-
uaricrckiomiju (CLLA) i ouabranc slucajcvc za CAS. U
bolcsnika s mozuanim uuarom osobiiu pozornosi zahiijcva-
ju oni s uuarom u progrcsiji. 1akovi bolcsnici procjcnjuju
sc prcma nacclima hiinc vaskularnc kirurgijc. Ulirazvucni
kriicriji koji inuiciraju poircbu za CLA su: >257 cholu-
ccninosii, hcicrogcnosi, ianki pokrov s nckroiicnom jcz-
grom, hcmoragija u plak, lipcmicni, ulccrirani i razlisiani
plak. Ircmua bi CLA ircbala biii jcuina prava prcvcncija
mozuanog uuara, broj opcracija u asimpiomaiskih bolcsni-
ka polagano rasic. Razlogc ircba iraziii u poicskoama ua
sc posiignc znacajan broj pravilno ranuomiziranih bolcsni-
ka, u sirokoj varijaciji viialnc siaiisiikc, sirahu ou ncuro-
loskih komplikacija, smanjcnom razumijcvanju mogunosii
UZV i irauicionalnom nacinu misljcnja. CLLA izglcua
korisna alicrnaiiva klasicnoj" CLA u bolcsnika s ocuvanim
kolaicralnim krvoiokom, u bolcsnika s rizikom razvoja rcs-
icnozc, u onih bcz viuljivc mozuanc infarkcijc i u bolcsni-
ka s uisialnom sicnozom, ali nc uo bazc lubanjc. CLLA jc
prihvailjiv zahvai u rukama kirurga koji jc izucio opcraciju
pou nauglcuanjcm mcniora i u bolnicama kojc praic
bolcsnikc uuplcks-sonografijom i publiciraju njihovc rczul-
iaic. 1razci alicrnaiivnc mogunosii lijcccnja, u razuoblju
1995.-1997. pcrkuiana iransluminalna karoiiuna angioplas-
iika (I1CA) usporcocna s CLA imala jc visc ncuroloskih
komplikacija i vci uuio ranc rcsicnozc. Rczuliaii CAS-a
1996.-1998. u izabranih bolcsnika bili su usporcuivi s CLA,
ali sa znaino losijim rczuliaiom nakon sckunuarnog sicn-
iinga. Srcusiva ccrcbralnc zasiiic uvcucna u Luropi kra-
jcm `90.-iih znacajno su unaprijcuila rczuliaic CAS-a. Irc-
ma Ncw York CBAS Conscnsus 1999. i Iarma ML1 Cri-
icria 2001, CAS nijc pogouan u bolcsnika niskog rizika, kou
pcirificiranc bifurkacijc, u bolcsii s floiirajuim i akuinim
irombom i u bolcsnika s priuruzcnom sicnozom zajcunickc
karoiiunc aricrijc. Ircporucljivc inuikacijc za CAS su:
sicnoza izvorisia ili ucbla zajcunickc karoiiuc, bolcsnik
visokog rizika, visoka sicnoza unuiarnjc karoiiuc i vrai
ncuosiupan za oivorcnu kirurgiju. Siroko prihvacna, ali nc
pouupria prcma LBM, inuikacija za CAS jc glaika karoiiuna
rcsicnoza. Ako pozornosi obraiimo na zajcunisivo ka-
roiiunc i koronarnc bolcsii (u RH 187-227 koronarnih
bolcsnika), iznosc sc ucialjni kriicriji za CLA/CAS u iak-
`98, Zagrcb `00, Cyprus `01 anu Lonuon '02) mcciings havc
mauc a significani sicp forwaru by inirouucing ihc guali-
iaiivc in auuiiion io ihc cxisiing guaniiiaiivc plaguc anal-
ysis. During ihc pasi uccauc, ihc fasi ucvclopmcni of
noninvasivc uiagnosis has imposcu ihc unavoiuablc rc-
cvaluaiion of aricriography as a golu 'sianuaru`. Sincc 1995,
ihc non-opcraior ucpcnucni criicria havc bccn ucfincu in
ihc ulirasounu (US) anu compuicu iomography (C1)
uiagnosis. Hcalih Carc Commissions havc bcgun graniing
auihorizaiion io Lxccllcncc Ccnicrs in US Diagnosis. !n
2002, caroiiu uiscasc has bccn caicgorizcu inio asympiom-
aiic or sympiomaiic, liablc io longiiuuinal CLA, liablc io
cvcrsion cnuaricrcciomy (CLLA), anu sclccicu cascs for
CAS. Among sirokc paiicnis, carc shoulu bc cspccially paiu
io ihosc wiih sirokc in progrcssion. 1hcsc paiicnis shoulu
bc cvaluaicu accoruing io ihc principlcs of cmcrgcncy
vascular surgcry. 1hc US criicria inuicaiing ihc nccu of
CLA arc: >257 ccholuccncy, hcicrogcnciiy, ihin cap wiih
a nccroiic nuclcus, hcmorrhagc inio ihc plaguc, anu lipcm-
ic, ulccraicu anu ramificu plaguc. Alihough CLA shoulu
bc ihc only iruc prcvcniion of sirokc, ihc numbcr of opcr-
aiions in asympiomaiic paiicnis is on a grauual incrcasc.
1hc rcasons for ihis lic in uifficuliics io gci a significani
numbcr of propcrly ranuomizcu paiicnis, wiuc variaiion in
viial siaiisiics, fcar from ncurologic complicaiions, poor
unucrsianuing of ihc possibiliiics of US uiagnosis, anu
irauiiional way of ihinking.
CLLA appcars io bc a uscful alicrnaiivc io 'classic` CLA
in paiicnis wiih prcscrvcu collaicral circulaiion, ihosc ai
risk of rcsicnosis, ihosc frcc from visiblc ccrcbral infarc-
iion, anu ihosc wiih uisial sicnosis bui noi io ihc basc of
ihc skull. CLLA is an acccpiablc proccuurc in ihc hanus
of a surgcon who has masicrcu ii unucr appropriaic supcr-
vision anu in hospiials whcrc paiicnis arc followcu-up by
uuplcx sonography anu ihcir rcsulis arc publishcu in pro-
fcssional pcriouicals.
!n scarch for alicrnaiivc ircaimcni moualiiics, compar-
ison of pcrcuiancous iransluminal caroiiu angioplasiy
(I1CA) anu CLA conuucicu uuring ihc 1995-1997 pcri-
ou showcu ihc formcr io bc associaicu wiih a highcr raic
of ncurologic complicaiions anu carly rcsicnosis. 1hc rc-
sulis on CAS, obiaincu bciwccn 1996 anu 1998 in sclcci-
cu paiicnis, wcrc comparablc wiih CLA rcsulis, howcvcr,
wiih a consiucrably poorcr rcsulis aficr scconuary sicni-
ing. 1hc agcnis for ccrcbral proicciion, inirouuccu in
Luropc iowarus ihc cnu of 1990s, havc significanily im-
provcu CAS rcsulis. Accoruing io ihc Ncw York CBAS
Conscnsus from 1999 anu Iarma ML1 Criicria from 2001,
CAS is noi auvisablc in low risk paiicnis, pcirificu bifur-
caiion, floaiing anu acuic ihrombus, anu in paiicnis wiih
associaicu common caroiiu aricry sicnosis. 1hc rccom-
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 45
ovih bolcsnika razuijcljcnih u 8 jasno ucfiniranih pouskupi-
na. Na kraju prcosiajc pouosia piianja. Ncka su: Sio ura-
uiii s karoiiunom sicnozom ispou 507 koja uzrokujc ncu-
roloski ucficii: Kojc su novc osobiiosii plaka povczanc s
ncuroloskim ucficiiom: Kako mozcmo unaprijcuiii ccrc-
bralnu zasiiiu: Koji jc opiimalan uuio CLA/CAS: Sio jc
najbolja mcuikamcnina icrapija karoiiunc bolcsii: Gcns-
ka icrapija i karoiiuna bolcsi:
mcnucu inuicaiions for CAS arc: sicnosis of ihc origin or
irunk of ihc common caroiiu, high risk paiicnis, high
sicnosis of inicrnal caroiiu, anu ncck inacccssibiliiy for
opcn surgcry. A wiucly auopicu bui noi LBM supporicu
inuicaiion for CAS is smooih caroiiu rcsicnosis.
Consiucring ihc caroiiu anu coronary comorbiuiiy (187
- 227 of coronary paiicnis in Croaiia), uciailcu criicria for
CLA/CAS in ihcsc paiicnis, caicgorizcu inio 8 uisiincily
ucfincu subgroups, arc prcscnicu.
Ai ihc cnu, a numbcr of gucsiions rcmain opcn, such
as: Whai io uo wiih a caroiiu sicnosis <507 which causcs
ncurologic ucficii: Whai arc ihc ncwly rccognizcu plaguc
fcaiurcs associaicu wiih ncurologic ucficii: How io im-
provc ccrcbral proicciion: Whai is ihc opiimal proporiion
of CLA/CAS: Whai is ihc bcsi mcuicamcnious ihcrapy for
caroiiu uiscasc: Gcnc ihcrapy anu caroiiu uiscasc:
S\RGICAI IROC!!\R!S O^ !XTRACRAÎAI C!R!HRAI
ART!RI!S I^ TI! IR!\!^TIO^ OI STROK!
KIR\RSKI IOST\ICI Â
!KSTRAKRAÎJSKIM C!R!HRAIÎM ART!RIJAMA
\ IR!\!^CIJI MOZ!AÔG \!ARA
Drago Dc Syo
Dcparimcni of Vascular anu Lnuovascular Surgcry, Univcrsiiy Dcparimcni of Surgcry,
Scsirc milosrunicc Univcrsiiy Hospiial, Zagrcb, Croaiia
Oujcl za vaskularnu i cnuovaskularnu kirurgiju Kirurskc klinikc, Klinicka bolnica ,Scsirc milosrunicc, Zagrcb
1hc main aim of all surgical proccuurcs on cxiracrani-
al ccrcbral aricrics (cnuaricrcciomy, anaiomic anu cxira-
anaiomic auiologous anu alloplasiic bypasscs, iransposi-
iions anu aricrial rcscciions wiih ncoanasiomoscs, anu
cnuovascular proccuurcs such as I1A wiih or wiihoui
sicni) is prcvcniion of sirokc or iis scvcrc rccurrcncc. Sur-
gical ircaimcni is mosily inuicaicu in orucr io climinaic
ihc sympioms of iransicni ccrcbral uysfunciion, which frc-
gucnily prcuici a sirokc, bui also in asympiomaiic paiicnis
ihrcaicncu by auvanccu sicnoscs, obliicraiions, or ulccr-
aicu plagucs.
!n almosi 907 of cascs, ihc causc of ccrcbrovascular
uiscasc (CVD) is aihcrosclcrosis or occlusivc aricrial uis-
Svi kirurski posiupci na cksirakranijskim ccrcbralnim
aricrijama (cnuaricrckiomija, anaiomska i cksiraanaiom-
ska auiologna i aloplasiicna prcmosicnja, iranspozicijc i
rcsckcijc aricrija s ncoanasiomozama, ic cnuovaskularni
zahvaii, kao I1A s ili bcz sicnia) imaju prvcnsivcno prc-
vcniivan konccpi lijcccnja s ciljcm sprjccavanja mozuanog
uuara ili njcgovog iczcg rcciuiva. Kirursko jc lijcccnjc naj-
ccsc inuicirano kako bi sc oiklonili simpiomi prolaznih
uisfunkcija mozga, koji ccsio nagovjcsiavaju mozuani uuar,
ali i kou asimpiomaiskih bolcsnika kojc ugrozavaju uzna-
prcuovalc sicnozc, obliicracijc ili ulccrirani plakovi. Naimc,
u goiovo 907 slucajcva uzrok jc ccrcbrovaskularnc bolcsii
(CVB) aicrosklcroza, ounosno okluzivna bolcsi aricrija,
46 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
rijciko i razni aricriiisi. Osialc bolcsii i sianja kojc mogu
biii uzrokom CVB i prcumci kirurskog lijcccnja su: prcsa-
vinua (//r//r), ioriuoziicii, clongacijc i pciljasic ivorbc
mozgovnih aricrija, priroocnc anomalijc (aplazija, hipo-
plazija, aiipican iijck i polazisic krvnih zila), komprcsija
aricrija, iraumaiskc i jairogcnc ozljcuc krvnih zila, fibro-
muskularna uisplazija i raznc ancurizmc. Akuini ili progrc-
sivni mozuani uuar samo sc iznimno i u poscbnim okolnos-
iima mozc kirurski lijcciii, a zbog visokih siopa smrinosii
(87-287) opcracija na mozgovnim aricrijama najccsc jc
iracionalna. U iom su siauiju CVB (!!!. klinicki siauij) bolji
rczuliaii konzcrvaiivnog lijcccnja. Kou bolcsnika s
mozuanim uuarom inuiciran jc hiian ncuroloski irciman i
lijcccnjc u jcuinicama inicnzivnc ncuroloskc skrbi. Irika-
zani su svi kirurski posiupci s poscbnim osvriom na karoiiu-
nu cnuaricrckiomiju koja ima najvisu razinu znansivcnc
valorizacijc na icmclju rczuliaia muliiccniricnih ranuomi-
ziranih siuuija glcuc uugorocnih rczuliaia lijcccnja i kriic-
rija inuiciranja.
U razuoblju ou 1970. uo 15. kolovoza 2002. gouinc na
Oujclu za vaskularnu i cnuovaskularnu kirurgiju Kirurskc
klinikc Klinickc bolnicc ,Scsirc milosrunicc ukupno su
ucinjcnc 1993 karoiiuc cnuaricrckiomijc u 1879 bolcsni-
ka (114 jc bolcsnika opcrirano bilaicralno). Srcunja uob
opcriranih iznosi 64,18,4 (raspon 38-98) gouina. Opcri-
rano jc 518 zcna i 1361 muskarac, sio prcusiavlja najvci
broj opcriranih u jcunoj usianovi u Hrvaiskoj. Maksimal-
no sianuaruiziranom opcracijskom ichnikom koja jc na
icmclju vlasiiiih isirazivanja hcmouinamikc prilagoocna
nozogcnciskom iipu karoiiunc bifurkacijc posiignuii su
rczuliaii usporcuivi s najboljima u svijciu.
casc, anu rarcly various aricriiiucs. Oihcr uiscascs anu
conuiiions ihai may causc CVD anu arc surgically managcu
incluuc kinkings, ioriuosiiics, clongaiions anu loop forma-
iions of ccrcbral aricrics, congcniial anomalics (aplasia,
hypoplasia, aiypical coursc anu origin of bloou vcsscls),
aricrial comprcssion, iraumaiic anu iairogcnic lcsions of
bloou vcsscls, fibromuscular uysplasia, anu various ancu-
rysms.
Acuic or progrcssivc sirokc can only cxccpiionally anu
in spccific circumsianccs bc surgically ircaicu. An opcra-
iion on ccrcbral aricrics is mosily irraiional bccausc of ihc
high morialiiy raics (87 - 287). Ai ihis siagc of CVD (clin-
ical siagc !!!), conscrvaiivc ircaimcni yiclus bciicr rcsulis.
!n sirokc paiicnis, urgcni ncurologic ircaimcni anu man-
agcmcni in ncurologic inicnsivc carc uniis arc inuicaicu.
Ircscniaiion is mauc of all surgical proccuurcs, wiih
spccial rcfcrcncc io caroiiu cnuaricrcciomy, which has
rcccivcu ihc highcsi lcvcl of scicniific valiuaiion bascu on
ihc rcsulis of ranuomizcu muliiccnicr siuuics in icrms of
longicrm ihcrapcuiic rcsulis anu inuicaiion criicria.
Irom 1970 iill Augusi 15, 2002, a ioial of 1993 caroiiu
cnuaricrcciomics in 1879 paiicnis (114 paiicnis wcrc
opcraicu on bilaicrally) wcrc pcrformcu ai ihc Dcpari-
mcni of Vascular anu Lnuovascular Surgcry, Univcrsiiy
Dcparimcni of Surgcry, Scsirc milosrunicc Univcrsiiy
Hospiial, Zagrcb, making ihc grcaicsi numbcr of paiicnis
opcraicu on ai a singlc insiiiuiion in Croaiia. 1hcrc wcrc
518 fcmalc anu 1361 malc paiicnis, mcan agc 64.18.4
(rangc 38-98) ycars. 1hc rcsulis comparablc wiih ihc bcsi
rcsulis rcporicu in ihc worlu wcrc achicvcu using ihc
maximally sianuaruizcu opcraiivc icchniguc, aujusicu io
ihc nosogcnic iypc of caroiiu bifurcaiion on ihc basis of
our own hcmouynamic rcscarch.
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 47
Main 1opic V! V!. glavna icma
kLHAlLl1A1lCN lN S1kClL lA1lLN1S
kLHAlLl1ACl}A MCZDANCC UDAkA
R!IAHIIITATIO^ I^ STROK! IATI!^TS
R!IAHIIITACIJA HOI!SÎKA ÂKO^ MOZ!AÔG \!ARA
Silva Buikovi-Soluo
!n sirokc paiicnis rchabiliiaiion musi bc a polyvalcni,
profcssionally wcll organizcu anu cconomical proccss.
Siruciural complcxiiy of ihc ccniral ncrvous sysicm func-
iions ucicrmincs io a grcai cxicni iis poicniial for rcgcn-
craiion anu cspccially for rccovcry or rcsiiiuiion of iis func-
iions: moior, scnsory, inicllcciual, cic. !i is jusi ihis com-
plcxiiy, anu cspccially ihc rising prcvalcncc of sirokc, ihai
rcguirc a muliiuisciplinary icam work.
1hc icam shoulu bc lcu by a ncurologisi, who will makc
ihc causal anu paihophysiological uiagnosis anu cvaluaic
ihc prognosiic possibiliiics of ihc paiicni, on ihc basis of
ihc ncw conccpis in ncuroscicncc anu ncurobiochcmical
rcscarch; ihcn, iogcihcr wiih oihcr icam mcmbcrs, hc will
ucsign a grauual program of raiional anu funciional rcha-
biliiaiion. A plan of work bascu on ihc rchabiliiaiion oui-
comc csiimaic shoulu bc ucvclopcu, ihc main gucsiions
bcing: Who:, Whcrc:, anu Whcn:
1hc carlicsi possiblc, iargcicu, highly uiffcrcniiaicu
uiagnosiic proccuurcs arc crucial for accuraic cvaluaiion of
ihc iypc of sirokc, which is ihc basis of ihc rchabiliiaiion
schcuulc. Rchabiliiaiion is uiviucu inio four main siagcs:
carly rchabiliiaiion, rchabiliiaiion on viial funciion siabi-
lizaiion, rchabiliiaiion following physical rccovcry anu
pariial pcrsonal inucpcnucncc of hospiial carc, anu rcha-
biliiaiion follow-up (on ouipaiicni basis, mobilc icams, anu
communiiy bascu rchabiliiaiion). 1hc possiblc usc of
currcni mcihous of funciional rcsioraiivc rchabiliiaiion,
Rchabiliiacija oboljclih ou mozuanog uuara mora biii
polivalcnian, sirucno uobro organiziran i ckonomican pro-
ccs. Slozcnosi sirukiura funkcija srcuisnjcga zivcanog su-
suiava ourcoujc u znainoj mjcri njcgovu spososbnosi rc-
gcncracijc i poglaviio oporavka ili ponovnog usposiavlja-
nja (rcsiauracijc) njcgovih funkcija: moiorickih, osjciilnih,
iniclckiualnih i urugih. Upravo zbog slozcnosii, a osobiio
zbog porasia broja oboljclih ou mozuanog uuara poircban
jc muliiuisciplinarni iimski" rau. Vooa iima ircba biii ncu-
rolog koji mora na osnovama novih spoznaja iz ncuroznano-
sii i ncurobiokcmijskih isirazivanja posiaviii kauzalnu i
paiofiziolosku uijagnozu i prognosiickc mogunosii bolc-
snika, ic s osialim clanovima iima uivruiii siupnjcviii pro-
gram racionalnc i funkcijskc rchabiliiacijc. Ioircbno jc raz-
rauiii plan organizacijc raua koji sc zasniva na procjcni isho-
ua rchabiliiacijc, a osnovni upiii su: 1ko:, Gujc: i Kaua:.
Kljucno piianjc jc sio ranija, ciljana, visokouifcrcnina ui-
jagnosiicka obraua raui procjcnc iipa mozuanog uuara, koja
jc osnova pri izraui plana rchabiliiacijc. Osnovna poujcla
jc u cciiri siupnja: rana rchabiliiacija, rchabiliiacija pri sia-
bilizaciji viialnih funkcija, rchabiliiacija nakon fizickog opo-
ravka i ujclomicnc osobnc ncovisnosii o siacionarnoj mc-
uicinskoj skrbi, i pracnjc rchabiliiacijc (ambulanino, po-
krcini iimovi i rchabiliiacija u zajcunici). Iriiom ircba pro-
cijcniii i mogunosii cvcniualnc primjcnc suvrcmcnih mc-
ioua funkcijskc rcsiauraiivnc rchabiliiacijc koju cinc ko-
mplcksni oblici lijcccnja, kao implaniacija ourcocnih
48 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
clckirosiimulacijskih clckiroua, ic mouifikacija paioloskih
funkcija u cilju njihovc uporabc raui uspoiavljanja novog
oblika scnzomoiornc konirolc kao mogunosi moucrnc
rcsiauraiivnc ncurologijc. Ovo jc ucinkoviio jcunako za
oporavak scnzomoiornih funkcija, ukljucujui afckiivnu
samokonirolu, priccm sc kombiniraju fizikalno icrapijskc,
ncurokirurskc, ncurofarmakoloskc i psiholoskc mciouc,
ovisno o sianju i fazi rchabiliiacijc. ]cuna ou vaznih prci-
posiavka za sio bolji rczuliai lijcccnja bolcsnika s moz-
uanim uuarom jc nc samo rani pocciak, ncgo i prccizno po-
siavljanjc programa rchabiliiacijc icmcljcm koniinuiranc
funkcijskc uijagnosiikc.
consisiing of complcx moucs of ircaimcni such as implan-
iaiion of clccirosiimulaiing clcciroucs, shoulu ihcrcby also
bc iakcn in consiucraiion. Also, mouificaiion of paiholog-
ic funciions in orucr io usc ihcm for ihc csiablishmcni of
ihc ncw form of scnsorimoior conirol shoulu bc consiucrcu
as a moualiiy of moucrn rcsioraiivc ncurology. 1his also
hclps in ihc scnsorimoior funciion rccovcry, incluuing af-
fcciivc sclf-conirol, whcrcby ihc physioihcrapcuiic, ncu-
rosurgical, ncuropharmacologic anu psychological mcihous
arc uscu in various combinaiions, ucpcnuing on ihc paiicni
conuiiion anu siagc of rchabiliiaiion.
Bcsiucs iis carly bcginning, prccisc ucicrminaiion of
ihc program of rchabiliiaiion bascu on ihc coniinuous
funciional uiagnosis is anoihcr imporiani prcconuiiion for
a favorablc ihcrapcuiic ouicomc of sirokc paiicnis.
^!\ROISYCIOIOGICAI !\AI\ATIO^ OI COGÎTI\!
I\^CTIO^S I^ STROK! IATI!^TS
^!\ROISIIOIOGIJSKA IROCJ!Â KOGÎTI\ÎI I\^KCIJA
ÂKO^ MOZ!AÔG \!ARA
Mirjana Vlaucii
Sirokc causcs significani icmporary anu pcrmancni
uisabiliiics. Bcsiucs ncurologic ucficiis, cogniiivc funciion
impairmcnis havc bccn mosi cxicnsivcly invcsiigaicu.
Siuuics havc shown ihai ihc mosi inicnsivc rccovcry of
ihcsc impairmcnis occurs wiihin ihc firsi ihrcc monihs
aficr ihc sirokc, whcrcaficr rcsiuual anu mosily pcrmancni
ucficiis pcrsisi in onc ihiru of sirokc paiicnis.
Cogniiivc impairmcnis may manifcsi as spccific ucfi-
ciis ihai can bc asscsscu on ncurologic cxaminaiion (c.g.,
homonymous hcmianopia, iclcgraphic spccch), howcvcr,
ihcy morc frcgucnily occur as complcx ucficiis ihai rcguirc
ncuropsychological cvaluaiion for complcic asscssmcni.
Ncuropsychology ucals wiih ihc siuuy of conncciion bc-
iwccn ihc ccniral ncrvous siruciurcs anu bchavior. Bchav-
ior incluucs ihrcc funciional sysicms: cogniiivc funciions,
cmoiionaliiy, anu cxccuiivc or conirol funciions. Cogniiivc
funciions havc bccn mosi ihoroughly invcsiigaicu. Cog-
Mozuani uuar uzrokujc znacajna privrcmcna i irajna
oncsposobljcnja oboljclc osobc. Uz ncuroloska osiccnja
najccsc su ispiiivani porcmcaji kogniiivnog funkcionira-
nja. !sirazivanja su pokazala ua jc njihov najinicnzivniji opo-
ravak unuiar prva iri mjcscca nakon inciucnia, a nakon iog
razuoblja u 1/3 slucajcva zaosiaju osiccnja koja su onua
najccsc i irajna. Kogniiivna sc osiccnja mogu javiii kao
spccificni ucfckii kojc jc moguc procijcniii iijckom ncu-
roloskog prcglcua (npr. homonimna hcmianopsija, iclc-
grafski govor), ali znaino ccsc kao komplcksni ucficiii za
ciju jc poipunu procjcnu poircbna ncuropsihologijska cva-
luacija. Ncuropsihologija sc bavi ispiiivanjcm vczc izmcou
srcuisnjih zivcanih sirukiura i ponasanja. Ionasanjc obuh-
vaa iri funkcionalna susiava: kogniiivnc funkcijc, cmocio-
nalnosi i izvrsnc, konirolnc funkcijc. U najvcoj su mjcri
ispiiivanc kogniiivnc, ounosno spoznajnc funkcijc. Kogni-
iivno funkcioniranjc obuhvaa: rcccpiivnc funkcijc (spo-
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 49
sobnosi primanja, klasificiranja i inicgriranja informacija),
misljcnjc (sposobnosi organizacijc i rcorganizacijc infor-
macija), pamcnjc i uccnjc (pohrana i cvokacija informaci-
ja), ic cksprcsivnc funkcijc (izvrsavanjc ili priopavanjc
informacija). U posljcunjcm jc sioljcu glavno zanimanjc
bilo usmjcrcno na oikrivanjc ccrcbralnc lokalizacijc visih
mcnialnih funkcija. Zaunja uva ucsciljcc, kao rczuliai
novih spoznaja o funkcioniranju ljuuskog uma razvio sc
prisiup koji uajc vaznosi uisiribuiranim funkcijama, a ounc-
uavno sc ova uva prisiupa pokusavaju objcuiniii. Lokali-
ziranc su funkcijc govor, ciianjc, pisanjc, racunanjc, visa
moiorna konirola izvcubc - u uominaninoj hcmisfcri, a
vizuo-pcrccpiivnc, vizuo-spacijalnc i konsirukcijskc spo-
sobnosii, kao i prozouicki aspckii govora - u ncuominani-
noj hcmisfcri. Disiribuiranc kogniiivnc funkcijc nisu loka-
liziranc, imaju uisiribuiranu ncuralnu osnovu, a io su pam-
cnjc, visc fronialnc izvrsnc funkcijc ic pozornosi i kon-
ccniracija. Ncuropsihologijska procjcna jc opsczan posiu-
pak koji sc sasioji ou opscrvacijc klinicara, primjcnc baic-
rijc icsiova kao i urugih ichnika ispiiivanja, ic prikuplja-
nja pouaiaka o psihosocijalnoj i mcuicinskoj povijcsii obo-
ljclog, kao i onih kojc mozc uaii obiiclj ili bliznji. Iouaci
kojc uaju ncuropsihologijski icsiovi moraju biii iumaccni
na kvaniiiaiivnoj, ali i kvaliiaiivnoj razini uzimajui u obzir
jcuinsivcnosi svakog pojcuinca. U inicrprciaciji rczuliaia
poircbno jc sivoriii primjcrcnu osnovu za usporcubu, uzi-
majui u obzir uob, obrazovnu razinu, sociockonomski sia-
ius i kuliuralni okvir, uz pokusaj ourcocnja prcmorbiunc
razinc funkcioniranja. Nakon mozuanog uuara kogniiivni
porcmcaji su ccsii, a u najvcoj su mjcri pogoocni pam-
cnjc, pozornosi i konccniracija, govor, vizuopcrccpiivnc
i konsirukcijskc sposobnosii, ic orijcniacija. Sisicmaiican
prcglcu vrsic i siupnja kogniiivnih osiccnja sio ga uajc
ncuropsihologijska cvaluacija pruza pouaikc vaznc za or-
ganizaciju proccsa rchabiliiacijc, procjcnu prcosialih spo-
sobnosii za profcsionalno funkcioniranjc kao i svakouncv-
ni zivoi ili ocjcnu poircbnih uvjcia zbrinjavanja bolcsnika.
Daljnja ispiiivanja na pourucju kogniiivnih funkcija, kao i
ncuropsihologijc uopc uaju mnosivo pouaiaka koji mogu
uoprinijcii boljcm razumijcvanju bolcsnika, naravi njcgovih
problcma, ic sivaranju uvjcia za poboljsanjc kvaliicic ziv-
ljcnja ljuui pogoocnih ovom bolcsu.
niiivc funciioning incluucs rcccpiivc funciions (abiliiy io
rcccivc, classify anu inicgraic informaiion), ihinking (abil-
iiy of organizing anu rcsiruciuring informaiion), mcmory
anu lcarning (informaiion sioragc anu cvoking), anu cx-
prcssivc funciions (cxccuiing or communicaiing informa-
iion). !n ihc lasi ccniury, ihc inicrcsi was mainly focuscu
on ihc ucicciion of ccrcbral localizaiion of high mcnial
funciions. Ovcr ihc lasi iwo uccaucs, an approach ihai
rcspccis uisiribuicu funciions has bccn ucvclopcu as ihc
rcsuli of ihc ncw conccpis of ihc human minu funciion-
ing, anu sincc rcccnily aiicmpis havc bccn mauc io unify
ihcsc iwo approachcs. Localizcu funciions of spccch, rcau-
ing, wriiing, calculaiing, anu high moior conirol of cxccu-
iion arc locaicu in ihc uominani hcmisphcrc, whcrcas
visuopcrccpiivc, visuospccial anu consiruciion abiliiics as
wcll as ihc prosouic aspccis of spccch arc locaicu in ihc
nonuominani hcmisphcrc. Disiribuicu cogniiivc funciions
arc noi localizcu anu havc a uisiribuicu ncural basis, c.g.,
mcmory, high fronial cxccuiivc funciions, aiicniion anu
conccniraiion.
Ncuropsychological cvaluaiion is an cxicnsivc procc-
uurc consisiing of clinician`s obscrvaiion, a baiicry of icsis
anu oihcr icchnigucs of cxaminaiion, anu collcciion of uaia
on ihc paiicni`s psychosocial anu mcuical hisiory, incluu-
ing uaia availablc from ihc paiicni`s family mcmbcrs, rcl-
aiivcs anu fricnus. 1hc uaia prouuccu by ncuropsycholog-
ical icsis shoulu bc inicrprcicu ai boih gunaiiiaiivc anu
gualiiaiivc lcvcl, ihcrcby iaking cach inuiviuual`s uniguc-
ncss in consiucraiion. On ihc rcsuli inicrprciaiion, an
appropriaic basis for comparison shoulu bc formcu, con-
siucring ihc paiicni`s agc, lcvcl of cuucaiion, sociocconom-
ic siaius, anu culiural backgrounu, also aiicmpiing io uc-
finc ihc prcmorbiu lcvcl of funciioning. Cogniiivc impair-
mcnis arc guiic common scgucls of sirokc, mosily affcci-
ing ihc funciions of mcmory, aiicniion anu conccniraiion,
spccch, visuopcrccpiivc anu consiruciion abiliiics, anu
oricniaiion. 1hc sysicmaiic ovcrvicw of ihc iypc anu grauc
of cogniiivc impairmcnis, offcrcu by ncuropsychological
cvaluaiion, proviucs uaia of high rclcvancc for ihc organi-
zaiion of ihc proccss of rchabiliiaiion, asscssmcni of rc-
siuual abiliiics for profcssional funciioning anu uaily liv-
ing, or cvaluaiion of ihc conuiiions rcguircu for propcr
paiicni carc.
Auuiiional siuuics in ihc ficlu of cogniiivc funciions
anu in ncuropsychology in gcncral proviuc a largc bouy of
uaia ihai may coniribuic io bciicr unucrsianuing of ihc
paiicnis anu ihc naiurc of ihcir problcms, anu io cnsurc
conuiiions for improvcmcni of ihc paiicni gualiiy of lifc.
50 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
SI!!CI R!IAHIIITATIO^ I^ STROK! IATI!^TS
R!IAHIIITACIJA GO\ORA ÂKO^ MOZ!AÔG \!ARA
Ruzica Rauanovi
Spccch funciion impairmcni conscgucniial io organic
ccrcbral uysfunciion is known io bc ihc mosi common cog-
niiivc ucficii cncounicrcu in paiicnis wiih ccrcbrovascu-
lar uiscasc. Aphasia is a frcgucni scgucl of sirokc, wiih a
prcvalcncc of as high as 217 - 247 of acuic siagc paiicnis.
!n somc paiicnis, aphasia shows sponiancous rcgrcssion,
so 107 - 187 of sirokc survivors havc aphasia (Irins anu
Vcrmculcn, 1991).
Aphasia ucsiroys ariiculaicu cxprcssion, iis comprc-
hcnsivcncss, wriiing anu rcauing, i.c. all four moualiiics of
languagc aciiviiics ai all iis lcvcls, from phoncmc ihrough
uiscoursc, from lciicr ihrough icxi, from auiomaicu
ihrough crcaiivc cxprcssion. 1hc rchabiliiaiion of spccch
communicaiion is a complcx, muliiuisciplinary anu vcry
longlasiing proccss. 1hc principlc of ihc carlicsi possiblc
inirouuciion of spccch ihcrapy has provcu uscful boih in
Croaiia anu worluwiuc.
Rchabiliiaiion implics noi only rcsiiiuiion of ihc
spccch-languagc funciion bui of ihc complcic pcrsonali-
iy anu, if possiblc, of ihc paiicni`s living cnvironmcni.
Spccch rchabiliiaiion shoulu bc iniiiiaicu immcuiaicly, i.c.
uuring ihc paiicni`s hospiial siay as soon as in siablc con-
uiiion. !i is nccucu io prcvcni fauing away of ihosc lan-
guagc funciions ihai havc noi bccn uamagcu bui simply
blockcu by ihc conuiiion. 1hc loss of iraccs for auuiiory,
kincsihciic anu visual imaging of ihc woru anu iis pcrccp-
iion shoulu bc avoiucu, which can bc achicvcu by carly
ircaimcni whilc ihc physiologic proccsscs arc siill frcshly
prcscrvcu.
Spccch ihcrapy in aphasic paiicnis shoulu rcly on ihc
following principlcs: carly rchabiliiaiion of ihc spccch anu
languagc; paiicni moiivaiion anu siimulaiing his aciivc
pariicipaiion in ihc rchabiliiaiion proccuurc; appropriaic,
uiagnosis bascu siimulaiion; iraining in ihosc compcnsa-
iory abiliiics ihai will bcsi hclp in unblocking of pariicu-
lar moualiiics of ihc languagc-spccch funciions, rcauing,
wriiing anu calculaiing; proviuing conuiiions for spccch
cxcrcisc anu complcic paiicni rchabiliiaiion ai ihc hospi-
ial, clinic for spccch rchabiliiaiion, or in ihc family; sirici-
Ioznaio jc ua ou svih kogniiivnih ucficiia u ccrcbro-
vaskularnim bolcsiima najccsc susrccmo porcmcaj u go-
vornim funkcijama koji jc posljcuica organskc ccrcbralnc
uisfunkcijc. Afazija jc ccsia posljcuica mozuanog uuara, s
uccsialosu ou cak 217 uo 247 bolcsnika u akuinoj fazi.
U ourcocnog broja bolcsnika afazija sc sponiano povucc pa
107-187 prczivjclih bolcsnika ima afaziju (Irins i Vcr-
mculcn, 1991.). Afazija razara ariikulirani izraz, njcgovo
razumijcvanjc, pisanjc i ciianjc, uaklc, sva cciiri moualiic-
ia jczicnc ujclainosii na svim njczinim razinama, ou fonc-
ma uo uiskursa, ou slova uo icksia, ounosno ou auiomaii-
ziranog uo sivaralackog izraza. Iroccs rchabiliiacijc govornc
komunikacijc jc slozcn, muliiuisciplinaran i izraziio uugo-
irajan. Nacclo sio ranijcg uvoocnja logopcuskc icrapijc
pokazalo sc uspjcsnim i u nas i u svijciu. Iou rchabiliiaci-
jom sc nc pourazumijcva samo obnavljanjc govorno-jczicnc
funkcijc, vc i cijclc licnosii i, ako jc moguc, i srcuinc u
kojoj bolcsnik zivi. Logopcuska rchabiliiacija ircbala bi
zapoccii oumah, jos uok jc bolcsnik u bolnici, kaua jc iz-
van zivoinc opasnosii. Ovo jc poircbno kako nc bi uoslo
uo zamiranja onih jczicnih funkcija kojc nisu osiccnc, ncgo
samo blokiranc uslijcu nasialog sianja. 1rcba izbjci gub-
ljcnjc iragova za auuiiivnu, kincsiciicnu i vizualnu prc-
uouzbu rijcci i njcno zapazanjc, a io sc posiizc ranim irci-
manom uok su fizioloski proccsi jos svjczi. Logopcuska
icrapija afazicara mora pocivaii na ourcocnim nacclima, a
io su: rana rchabiliiacija jczika i govora; moiivacija bolcsnika
i razvijanjc njcgovog suujclovanja u rchabiliiacijskom pos-
iupku; ougovarajua siimulacija koja pociva na uijagnosii-
ci; vjczbanjc onih kompcnzacijskih mogunosii kojc c
najvisc pomoi ucblokiranju pojcuinih moualiicia jczicno-
govornih funkcija, ciianja, pisanja i racunanja; sivaranjc
uvjcia za govornu vjczbu i poipunu rchabiliiaciju bolcsni-
ka u bolnici, u logopcuskoj ambulanii i u obiiclji; sirogo
inuiviuualiziran logopcuski irciman zasnovan na naravi
bolcsii (vrsii i siupnju gubiika govornih i osialih zura-
sivcnih funkcija), kao i na iipu licnosii i njcnom ponasa-
nju; ncunificirana icrapija mora polaziii ou iniclckiualnc
razinc bolcsnika, njcgovog maicrinjcg jczika i poziiivnog
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 51
oprcujcljcnja, kao i niza urugih cinilaca kojc jc bolcsnik prijc
oboljcnja upoircbljavao ili su igrali kakvu znacajnu ulogu u
njcgovom zivoiu. Biina jc jos suraunja s obiiclji i prihvaanjc
afazicnc osobc ou siranc obiiclji. Akiualni prisiupi lijcccnju
afazija ukljucuju: icrapiju voocnu psiholingvisiickim icori-
jama, kogniiivnu ncurorchabiliiaciju, kompjuiorskc ichni-
kc, psihosocijalni prisiup, farmakoicrapiju (jos na ckspcri-
mcnialnoj osnovi). Valjana prognoza afazijc sc mozc obicno
posiaviii unuiar prvog mjcscca nakon mozuanog uuara,
ovisno o jacini poccinih smcinji. Za prognozu oporavka
vazni su uob i zuravsivcno sianjc bolcsnika ic ciiologija i
opscg primarnc ozljcuc. Znainiji oporavak uogaoa sc u
prvih 6 mjcscci nakon nasiupa ucficiia. Sponiani oporavak
ou afazijc jc najuspjcsniji iijckom prva 3 mjcscca, ali sc
poboljsanja mogu uogouiii cak i kasnijc. Uccsialosi poi-
punog oporavka krcc sc ou 217 uo 507. Afazijc kou irau-
maiskih slucajcva oporavljaju sc brzc ou vaskularnih. Una-
ioc brojnoj liicraiuri o procjcni i lijcccnju afazijc, ick jc vrlo
malo napisano o samom zavrsciku icrapijc. Nasa saznanja
sicccna iskusivom kazuju ua logopcuska icrapija ircba ira-
jaii svc uoilc uok sc posiizc uspjch u oporavku poccinih
smcinji (1 uo 3 gouinc) i uok jc bolcsnik moiiviran. Uoccno
jc ua nakon zavrscika koniinuiranog logopcuskog ircima-
na uolazi uo siagnacijc ili rcgrcsijc oporavljcnih smcinji, ic
sc bolcsnici nakon jcunc gouinc ou zavrscika logopcuskc
icrapijc ponovno javljaju logopcuu.
ly inuiviuualizcu spccch paihology ircaimcni bascu on ihc
paiicni`s iypc of uisorucr (iypc anu grauc of ihc spccch
anu oihcr funciion impairmcnis), iypc of pcrsonaliiy, anu
bchavioral paiicrn; nonunificu ihcrapy shoulu siari from
ihc paiicni`s inicllcciual lcvcl, moihcr`s ionguc, posiiivc
aiiiiuuc, anu a numbcr of oihcr faciors ihc paiicni hau
bccn rcgularly using bcforc ihc uiscasc or playing a major
rolc in his lifc.
Coopcraiion wiih ihc paiicni`s family is also of para-
mouni imporiancc. 1hc currcni approachcs in ihc ircai-
mcni of aphasia incluuc ihc following: ihcrapy conuuci-
cu accoruing io psycholinguisiic ihcorics; cogniiivc ncu-
rorchabiliiaiion; compuicr icchnigucs; psychosocial ap-
proach; anu pharmacoihcrapy (siill in ihc cxpcrimcnial
phasc).
A goou prognosis of aphasia can usually bc mauc wiih-
in ihc firsi monih of sirokc onsci, ucpcnuing on ihc sc-
vcriiy of iniiial uisiurbanccs. 1hc prognosis of rccovcry
ucpcnus on ihc paiicni agc anu conuiiion, anu ihc ciiolo-
gy anu cxicni of primary lcsion. Consiucrablc rccovcry
occurs wiihin ihc firsi six monihs of ihc ucficii onsci.
Sponiancous rccovcry from aphasia is mosi succcssful
uuring ihc firsi ihrcc monihs, howcvcr, improvcmcnis can
also occur laicr. 1hc prcvalcncc of ioial rccovcry varics
bciwccn 217 anu 507.
1raumaiic aphasia rccovcrs fasicr ihan vascular apha-
sia. !n spiic of abunuancc liicraiurc on ihc cvaluaiion anu
ircaimcni of aphasia, liiilc has bccn rcporicu on ihcrapy
icrminaiion. Our knowlcugc bascu on cxpcricncc suggcsis
ihai spccch ihcrapy shoulu iakc as along as any succcss in
ihc rccovcry of iniiial uisiurbanccs is rccorucu (1-3 ycars)
anu ihc paiicni is moiivaicu for ii. 1crminaiion of coniin-
uous spccch ihcrapy has bccn obscrvcu io bc followcu by
siagnaiion or rcgrcssion of ihc rccovcrcu uisiurbanccs, anu
paiicnis prcscnicu again for spccch ihcrapy onc ycar af-
icr spccch ihcrapy complciion.
52 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
Q\AIITY OI III! A^! R!IAHIIITATIO^ I^ COMM\ÎTY
- II\I^G WITI STROK!
K\AIIT!TA ZI\OTA I R!IAHIIITACIJA \ ZAJ!!ÎCI
- ZI\J!TI S MOZ!AÎM \!AROM
Vcsna Scri
Univcrsiiy Dcparimcni of Ncurology, Scsirc milosrunicc Univcrsiiy Hospiial, Rcfcrcncc Ccnicr for Ncurovascular
Disorucrs, Minisiry of Hcalih of ihc Rcpublic of Croaiia, Zagrcb, Croaiia
Klinika za ncurologiju, Klinicka bolnica ,Scsirc milosrunicc,
Rchabiliiaiion is an inicgral pari of ihc managcmcni
of paiicnis wiih sirokc. A kcy io succcssful rchabiliiaiion
is a cooruinaicu icam approach ihai involvcs aciivc parii-
cipaiion by scvcral rchabiliiaiion spccialisis who can pro-
viuc scrviccs io paiicnis on a casc-by-casc basis. Rchabil-
iiaiion shoulu bcgin as soon as ihc paiicni is mcuically
siablc. Larly ircaimcni, coniinuing cncouragcmcni anu
oricniaiion iowarus ihc ouisiuc cnvironmcni arc impor-
iani. Luucaiion of ihc paiicni anu his family aboui sirokc
anu iis conscgucnccs is an imporiani sicp in rchabiliiaiion.
Iamily mcmbcrs shoulu bc informcu aboui ihc ncurolo-
gic impairmcni.
Mosi paiicnis will nccu cvaluaiion anu ircaimcni by
a physical ihcrapisi, a spccch paihologisi, anu an occupa-
iional ihcrapisi. !n somc cascs, vocaiional rchabiliiaiion
spccialisis, rccrcaiion ihcrapisis or ncuropsychologisi/cog-
niiivc rchabiliiaiion spccialisi will bc nccucu. 1hc involvc-
mcni of ihc nursing scrvicc also is criiical. 1hcsc profcs-
sionals shoulu asscss paiicnis anu iailor ircaimcni plan io
cach inuiviuual paiicni`s nccus. Ilans shoulu rcspcci ihc
wishcs of ihc paiicni anu his family as wcll as ihc paiicni`s
ncurologic anu gcncral mcuical siaius. Lach rchabiliiaiion
scrvicc spccializcs in uiffcrcni aspccis of ihc paiicni`s rc-
covcry.
Ihysical ihcrapy conccniraics on ihc following aspccis:
mobilizaiion, walking, major moior or scnsory impairmcni
of ihc limbs anu prcscripiion of ucviccs, such as a canc or
walkcr. Spccch paihology auurcsscs ihc following issucs:
uisorucrs of languagc, uisorucrs of ariiculaiion anu uisor-
ucrs of swallowing. Occupaiional ihcrapy focuscs on ihc
following issucs: finc movcmcnis of ihc hanu, arm func-
iion, uiilizaiion of iools anu assisiivc ucviccs, anu abiliiy
io funciion inucpcnucnily. Occupaiional anu physical ihc-
rapy shoulu cmphasizc using affccicu limbs anu achicving
Rchabiliiacija jc sasiavni uio lijcccnja bolcsnika s mo-
zuanim uuarom (MU). Za uspjcsnu rchabiliiaciju kljucan
jc usklaocni iimski prisiup koji ukljucujc ujclaino suujclo-
vanjc nckoliko spccijalisia u rchabiliiaciji koji bolcsniku
mogu pruziii skrb sirogo uicmcljcnu na svakom pojcui-
nacnom slucaju. S rchabiliiacijom ircba zapoccii cim jc
bolcsnik u mcuicinski siabilnom sianju. Vazno jc rano
lijcccnjc, sialno ohrabrivanjc i orijcniacija prcma vanjskoj
okolini. Obrazovanjc bolcsnika i njcgovc obiiclji o MU i
njcgovim posljcuicama vazan jc korak u rchabiliiaciji. Cla-
novc obiiclji ircba obavijcsiiii o ncuroloskom porcmca-
ju. U vcinc jc bolcsnika poircbna procjcna i lijcccnjc fi-
zioicrapcuia, logopcua i raunog icrapcuia. U nckim sluca-
jcvima poircbnc su uslugc ncuropsihologa/spccijalisia za
kogniiivnu rchabiliiaciju. Vcoma jc vazna i scsirinska uslu-
ga. Svi ovi sirucnjaci ircbaju procijcniii bolcsnika i plani-
raii lijcccnjc na icmclju poircba svakog pojcuinog bolcsni-
ka. Iriiom ircba u obzir uzcii zcljc bolcsnika i njcgovc
obiiclji, kao i bolcsnikov ncuroloski i opc mcuicinski sia-
ius. Svaka jc rchabiliiacijska sluzba spccijalizirana za ra-
zliciic viuovc bolcsnikova oporavka. Iizikalna icrapija usrc-
uoioccna jc na sljcucc aspckic: mobiliziranjc, houanjc,
vci moioricki ili scnzorni porcmcaj cksircmiicia i pro-
pisivanjc pomagala kao sio jc siap ili urcoaj za pomo pri
houanju. Iaiologija govora usmjcrcna jc na sljcuca piia-
nja: jczicnc porcmcajc, porcmcajc ariikulacijc i porc-
mcajc guianja. Rauna icrapija upucna jc na sljcuca pi-
ianja: fini pokrcii sakc i rukc, uporaba srcusiava za rau i
pomagala, ic sposobnosi ncovisnog funkcioniranja. U rau-
noj i fizikalnoj icrapiji naglasak ircba biii na upoircbi zah-
vacnih cksircmiicia i posiizanju sprcinosii pri jclu,
oblaccnju, osobnoj higijcni i urugim osnovnim poircbama.
Dok uvouni koraci u rchabiliiaciji pocinju u okruzcnju
akuinc skrbi, valja naciniii plan za ncprckiunu bolnicku i
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 53
izvanbolnicku rchabiliiaciju. Novi posiupci za pomo u
oporavku nakon MU ukljucuju icrapiju pokrciima iza-
zvanim ograniccnjima ic lijckovc za konirolu spasiiciicia.
Vjczbanjc pomou roboia, clckiricna siimulacija, icrapija
pomou magnciskog polja, naizmjcnicna komprcsija ic
inicnzivna fizikalna icrapija vrsic su lijcccnja kojc obcava-
ju. Irocjcnu bolcsnika ircba provouiii u rcuovnim vrcmcn-
skim razmacima iijckom oporavka ou MU. Vrsic i okru-
zcnja rchabiliiacijc prilagooavaju sc prcma bolcsnikovu
ougovoru i sianju. Cilj jc u svakog pojcuinca posiii najvcu
moguu razinu ncovisnosii. Dcprcsija jc ccsia nakon MU.
Iorcmcaj raspolozcnja mozc biii cmocionalni ougovor na
izncnaunu i pogubnu promjcnu u bolcsnikovu zivoiu i
ncovisnosii. Dcprcsija nakon MU nasiajc i kao organska
posljcuica mozuanc ozljcuc. 1akvc porcmcajc ircba occki-
vaii i lijcciii ih razuvjcravanjcm i razumijcvanjcm. Lmocio-
nalni porcmcaji mogu usporiii oporavak ou MU i ograniciii
ucinkoviiosi rchabiliiacijc. Ccsio jc poircbno savjciovanjc
i primjcna aniiucprcsiva. Na rchabiliiaciju povoljno uijccu
mlaoa zivoina uob, ograniccn scnzorni i moioricki ucficii,
ncporcmccna mcnialna funkcija i susrciljiva kuna oko-
lina. Bolcsnik, njcgova roubina i prijaiclji moraju shvaiiii
narav oncmoalosii i vjcrojainosi ua jc poboljsanjc moguc,
ali ick s vrcmcnom, uza sirpljcnjc i usirajnosi. Konacan cilj
rchabiliiacijc ircba biii osiguranjc ncprckiunog uugoirajnog
mcuicinskog lijcccnja i rchabiliiacijc koji c ispuniii zcljc
i poircbc bolcsnika i njcgovc obiiclji.
proficicncy in caiing, urcssing, ioilci funciions, anu oihcr
basic nccus.
Whilc ihc prcliminary sicps in rchabiliiaiion bcgin in
an acuic-carc sciiing, a plan shoulu bc ucvclopcu for con-
iinucu inpaiicni anu ouipaiicni rchabiliiaiion.
Ncw inicrvcniions io hclp moior rccovcry aficr sirokc
incluuc consiraini-inuuccu movcmcni ihcrapy anu mcu-
icaiions io conirol spasiiciiy. Iromising ihcrapics incluuc
roboi iraining, clccirical siimulaiion, magnciic ficlu ihc-
rapy, inicrmiiicni comprcssion anu inicnsivc physical ihc-
rapy.
Iaiicnis shoulu bc asscsscu ai rcgular inicrvals uuring
ihcir rccovcry from sirokc. 1hc iypcs anu sciiings of rc-
habiliiaiion arc aujusicu in rcsponsc io ihc paiicni`s rc-
sponscs anu conuiiion. 1hc goal will bc for ihc inuiviuual
io bc as inucpcnucni as possiblc.
Dcprcssion is common following sirokc. 1hc moou
uisorucr can bc an cmoiional rcsponsc io ihc suuucn anu
ucvasiaiing changc in ihc paiicni`s lifc anu inucpcnucncc.
Dcprcssion aficr sirokc is also an organic conscgucncc of
ihc brain injury. 1hcy shoulu bc cxpccicu anu ircaicu by
rcassurancc anu unucrsianuing. Lmoiional uisiurbanccs
can hampcr rccovcry from sirokc anu limii ihc cfficacy of
rchabiliiaiion. Oficn, counscling anu usc of aniiucprcs-
sanis arc nccucu.
Youngcr agc, limiicu scnsory anu moior ucficii, iniaci
mcnial funciion anu a hclpful homc cnvironmcni favor-
ably influcncc rchabiliiaiion. 1hc paiicni, rclaiivcs anu
fricnus musi unucrsianu ihc naiurc of ihc uisabiliiics anu
ihc likclihoou ihai improvcmcni can occur, bui only wiih
iimc, paiicncc anu pcrscvcrancc. 1hc uliimaic goal of ihc
rchabiliiaiion shoulu bc io proviuc coniinucu long-icrm
mcuical ircaimcni anu rchabiliiaiion ihai mcci ihc pa-
iicni`s anu family`s wishcs anu nccus.
54 /cIo c||n C|coI, \c|. 41, Supp|. 3, 2002
!II!!MIOIOGIC A^! !COÔMIC IARAM!T!RS
OI C!R!HRO\ASC\IAR !IS!AS! I^ CROATIA
!II!!MIOIOSKI I GOSIO!ARSKI IOKAZAT!IJI
C!R!HRO\ASK\IAR^! HOI!STI \ IR\ATSKOJ
Sijcpan 1urck, Vlasia Zcrjavi-Hrabak
Croaiian Chambcr of Commcrcc, Naiional !nsiiiuic of Iublic Hcalih, Zagrcb, Croaiia
Hrvaiska gospouarska komora, Hrvaiski zavou za javno zuravsivo, Zagrcb
1hc scconu half of ihc iwcniicih ccniury was charac-
icrizcu by a significani incrcasc in ihc prcvalcncc of chronic
nonconiagious uiscascs in all inuusirializcu counirics of ihc
worlu, which siimulaicu many cpiucmiologic siuuics ihai
showcu a high morialiiy raic for vascular uiscascs. 1hc
highcsi morialiiy raics wcrc rccorucu in ihc counirics of
ccniral anu casi Luropc (Lsionia 1401, Liihuania 1405,
anu Ukrainc 1490 p-r 100,000), anu lowcsi in Irancc, Spain
anu Swiizcrlanu (330, 399, anu 477/100,000, rcspcciivc-
ly). Ovcr ihc lasi uccauc, ihc lcauing causc of ucaih in
Croaiia wcrc ccrcbrovascular uiscascs. !n Croaiia, ihc sian-
uaruizcu morialiiy raic ai agc 0-64 in 1999 was 30.64/
100,000, whcrcas in Ausiria anu Slovcnia ii was 10.15/
100,000 anu 16.65/100,000, rcspcciivcly. 1hc sianuaruizcu
raic of all ucaihs from ccrcbrovascular uiscascs was also
founu io bc on an incrcasc anu was 186.65/100,000 in 1999,
as comparcu io 73.48/100,000 in Ausiria anu 92.01/100,000
in Slovcnia. Consiucring ihc incrcasing ircnu of ucaihs
aiiribuicu io ccrcbrovascular morbiuiiy in rcccni ycars in
Croaiia, whcrcas a uccrcasc has bccn rccorucu in oihcr
counirics owing io succcssful prcvcniion anu carly uiag-
nosis, wc iricu io calculaic objcciivc cosis ihai incluuc, in
auuiiion io ihc cosi of ircaimcni, work inabiliiy, rchabili-
iaiion, anu cconomic losscs. On ihc asscssmcni of non-
mcuical cosis, wc followcu ihc currcni mcasurcs uscu by
insurancc companics accoruing io ihc mcan lifc cxpccian-
cy.
Accoruing io cpiucmiologic uaia of ihc Naiional !nsii-
iuic of Iublic Hcalih, 8175 paiicnis of boih scxcs, 1342
(16.417) of ihcm in ihc prouuciivc agc <65, uicu uuring
1999 from ccrcbrovascular uiscascs. 1hc cosis of ihcir
ircaimcni wcrc 81,227,580 HRK, anu losscs from prcma-
iurc ucaih 202,631,000 HRK. Upon calculaiing (cvalua-
iing) all cosis cxccpi for ihc sianuaru cosi of ircaimcni ai
all hcalih carc lcvcls, ihc cosis uuc io lifc cxpcciancy rc-
uuciion as comparcu wiih ihc mcan lifc cxpcciancy for
Croaiia in 1999 wcrc asscsscu.
Druga polovica uvaucscioga sioljca obiljczcna jc
znacajnim porasiom kronicnih nczaraznih bolcsii u svim
razvijcnim zcmljama svijcia,.sio jc poiaklo brojnc cpiuc-
mioloskc siuuijc kojc su pokazalc visoku siopu morialiic-
ia oboljclih ou bolcsii krvozilnog susiava. Siopa smrinosii
bila jc najvisa u zcmljama srcuisnjc i isiocnc Luropc (Ls-
ioniji 1.401, Laiviji 1.405 i Ukrajini 1.490/100.000 sianovni-
ka), a najnizc siopc zabiljczcnc su u Irancuskoj, Spanjol-
skoj i Svicarskoj (330, 399 ounosno 477/100.000 sianovni-
ka). Vouci uzrok smrii posljcunjcga ucsciljca u Hrvaiskoj
su ccrcbrovaskularnc bolcsii. Sianuaruizirana siopa umr-
lih u uobi ou 0-64 gouinc zivoia za 1999. g. jc 30,64/100.000
sianovnika, uok jc za isio razuobljc u Ausiriji 10,15, a u
Slovcniji 16,65. U porasiu jc sianuaruizirana siopa smri-
nosii svih umrlih ou ccrcbrovaskularnih bolcsii, pa jc 1999.
g. 186,65/100.000 sianovnika, uok jc u Ausiriji 73,48, a u
Slovcniji 92,01/100.000 sianovnika. S obzirom na porasi
broja umrlih posljcunjih gouina u nas, uok urugc zcmljc
biljczc smanjcnjc provoocnjcm uspjcsnc prcvcncijc i ranc
uijagnosiikc, pokusali smo izracunaii objckiivnc iroskovc
koji uz iroskovc lijcccnja ukljucuju raunu ncsposobnosi,
rchabiliiaciju i gubiikc u gospouarsivu. U procjcni ncmc-
uicinskih iroskova vouili smo sc vazcim mjcrilima osigu-
ravajuih urusiava prcma prosjccnoj occkivanoj uobi zivo-
ia. Na icmclju cpiucmioloskih pouaiaka Hrvaiskoga zavo-
ua za javno zuravsivo iijckom 1999. gouinc umrlo jc ou
ccrcbrovaskularnih bolcsii 8.175 osoba oba spola. Ircma
iim pouaicima 1.342 (16,417) umrlc osobc bilc su u
prouukiivnoj uobi uo 65 gouina zivoia. 1roskovi njihovog
lijcccnja iznosili su 81.227.580 kn, a gubiici zbog prcranc
smrii bili su 202.631.000 kn. Iri izracunu (procjcni) svih
iroskova osim sianuarunih iroskova lijcccnja u svim razi-
nama zuravsivcnc zasiiic izvrsili smo procjcnu iroskova
nasialih zbog skracnja zivoinc uobi prcma prosjccima
occkivanc zivoinc uobi u 1999.g. za Hrvaisku. 1ijckom
2000. gouinc u primarnoj zuravsivcnoj zasiiii lijcccno jc
42.111 oboljclih ou ccrcbrovaskularnih bolcsii, ou kojih jc
/cIo c||n C|coI, \c|. 41, Supp|. 3, 2002 55
During 2000, 42111 paiicnis wiih ccrcbrovascular uis-
cascs wcrc ircaicu ai primary hcalih carc; 18,003 of ihcm
wcrc hospiializcu, anu 8382 paiicnis uicu. 1hc cosi of
ircaimcni for ccrcbrovascular uiscascs was 1,450,623,897
HRK or 11.1077 of ioial hcalih insurancc cxpcnuiiurc in
2000. As ccrcbrovascular uiscascs occur as a conscgucncc
of risk faciors, ihc cosis of simuliancous ircaimcni of oih-
cr chronic nonconiagious uiscascs coulu noi bc singlcu oui.
1hc morbiuiiy anu morialiiy of ccrcbrovascular uiscas-
cs coulu bc rclaiivcly guickly rcuuccu by grauual bui sicauy
invcsimcni in ihc prcvcniion anu rapiu uiagnosis anu
managcmcni of acuic siaics. 1hc invcsicu rcsourccs woulu
bc rciurncu soon, whilc ihc prcscni cosis woulu bc signi-
ficanily rcuuccu (by 307 - 407), anu uircci savings for ihc
cconomic sysicm woulu bc rcalizcu, cvcniually rcsuliing
in an incrcasc of ihc gross naiional prouuci.
18.003 bolcsnika bolnicki lijcccno, uok su 8.382 bolcsnika
prcminula. 1ijckom 2000. gouinc iroskovi lijcccnja ou
ccrcbrovaskularnih bolcsii iznosili su 1.450.623.897 kn ili
11,1077 svcukupnih iroskova zuravsivcnog osiguranja za
2000. gouinu. S obzirom na io ua su ccrcbrovaskularnc
bolcsii posljcuica rizicnih cimbcnika, u iroskovima lijcccnja
nijc bilo moguc iskljuciii iroskovc isiouobnog lijcccnja i
urugih kronicnih nczaraznih bolcsii. Iosiupnim invcsiira-
njcm u prcvcnciju i brzu uijagnosiiku i lijcccnjc akuinih
sianja moglo bi sc rclaiivno brzo smanjiii pobol i smrinosi
ou ccrcbrovaskularnih bolcsii. Ulozcna srcusiva brzo bi sc
povraiila, uok bi sc posiojci iroskovi znacajno smanjili (za
307 uo 407) i osivarilc izravnc usicuc gospouarskom su-
siavu u cilju rasia bruio urusivcnog proizvoua.

Foreword: Second Congress of Croatian Stroke Society Drugi Kongres Hrvatskoga Dru Tva Za Prevenciju Mo Danog Udara

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Foreword: Second Congress of Croatian Stroke Society Drugi Kongres Hrvatskoga Dru Tva Za Prevenciju Mo Danog Udara

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/cIo c||n C|coI, \c|. 41, Supp|.

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