Geçici iskemik atak ve BT-negatif akut iskemi

Özet

Geçici iskemik atak, fokal nörolojik işlev bozukluğunun akut infarkt olmadan geçici olarak ortaya çıktığı klinik bir sendromdur; belirtilerin düzelmesi acil damar kaynaklı riski ortadan kaldırmaz. Kontrastsız BT hızlı biçimde intrakraniyal kanama, kitle ve belirgin yerleşmiş infarktı araştırır, ancak erken veya küçük akut iskemiyi dışlayamaz. BTA baş-boyun damarlarındaki semptomatik darlık ya da oklüzyonu gösterir; difüzyon MR akut infarktı saptamada BT'den daha duyarlıdır ve tanımın doku bileşenini aydınlatabilir. BT'nin negatifliğini nörolojik olay yokluğu gibi yorumlamak küçük infarktı ve yüksek riskli damar lezyonunu kaçırabilir.

Faz ve pencere

Kontrastsız tanısal

Kontrastsız BT'de erken iskemik değişiklikler arasında sulkus effasmanı, bazal gangliyon/subkortikal hipodensite ve kortikal gri-beyaz cevher ayrımının kaybı değerlendirilebilir.

BTA tanısal

Baş-boyun arteriyel lümenlerinde akut büyük damar kesilmesi, semptomla ilişkili stenoz, intraluminal trombüs, kollateral doluş ve anatomik varyantlar incelenir; normal BTA küçük damar veya BT-negatif doku iskemisini dışlamaz.

Önerilen pencereler: Beyin (G 80 / M 40), İnme (G 40 / M 40), Anjiyo (G 600 / M 150).

BT bulguları

• Kontrastsız BT'de kanama ve kitle etkisinin bulunmaması TIA veya akut iskemi olasılığını ortadan kaldırmaz; inceleme öncelikle önemli alternatifleri hızla dışlar.
• MCA alanında insular ribbon'ın silinmesi, lentiform nükleus kontur kaybı, gri-beyaz cevher ayrımında azalma ve sulkus effasmanı erken iskemi ipuçlarıdır.
• Akut infarkt hipoattenüasyonu ilgili arter alanında gelişir; erken dönemde ince, bölgesel ve karşı hemisferle asimetrik olabilir.
• Kronik enfarkt glioz ve ensefalomalaziye bağlı olarak yan komşu boşluk genişlemesi ve ventriküler dilateasyon gösterebilir.
• BTA'da intrakraniyal ICA veya MCA'da ani kesilme, semptomla uyumlu distal dal dolum kaybı ve kollateral pial damarlar eşlik edebilir.
• Damar duvarı kalsifikasyonu, fokal lümen daralması ve distal doluş azalması semptomatik intrakraniyal ateroskleroz için birlikte yorumlanır.
• Parankim BT'si normal ve BTA açık olsa bile küçük kortikal, laküner veya posterior fossa infarktı olabilir; difüzyon MR daha duyarlı testtir.

Normalde

Normal kontrastsız BT'de hemisferler simetrik, kortikal gri-beyaz cevher sınırı belirgin, insular korteks ve bazal gangliyonlar seçilebilir, sulkuslar doğal açıklıktadır; akut kanama veya fokal kitle etkisi bulunmaz. BTA'da intrakraniyal ICA, MCA ve ana dallar kontrastla devamlı dolar; şüpheli taraftaki lümen ve distal dal opasifikasyonunu karşı hemisferle karşılaştır, fakat normal görünümün BT-negatif akut infarktı dışlamadığını akılda tut.

Ayırıcı tanı

Akut iskemik infarkt

arter alanına uyan fokal gri-beyaz cevher silinmesi, insular ribbon/lentiform nükleus kaybı veya sulkus effasmanı görülebilir; erken BT normal kalabilir.

İntraserebral kanama

kontrastsız BT'de parankimal kan ve çevresinde kitle etkisi ile ortaya çıkar; CTA'da spot veya fırça işareti erken hematoma genişlemesini öngörmede kullanılır.

Hipoglisemi veya metabolik ensefalopati

diffüzyon ağırlıklı MR'da iç kapsül arkası, corona radiata ve korpus kallozum splenyumunda çift taraflı, geri döndürülebilir yüksek sinyaller görülebilir ve bu durum akut izkemik inme ile karışabilir.

Nöbet sonrası Todd parezisi

BT ve BTA normal olabilir veya geçici bölgesel ödem bulunabilir; klinik olayın nöbet özellikleri ve MR bulguları ayırıcıdır.

Migrenli hastalarda beyaz madde lezyon yükü kontrol grubuna göre belirgin şekilde daha yüksektir.

Kronik enfarkt glioz ve ensefalomalaziye bağlı olarak ventriküler ve subaraknoid boşluklarda genişleme gösterebilir; eşlik eden damar anomalileri veya kronik stenoz ayrınot edilir.

Tuzaklar

• Semptomların düzelmesini BT'de infarkt yokluğuyla eşitleme; doku temelli değerlendirmede klinik geçici olay da MR'da akut lezyon gösterebilir.
• Erken iskemi işaretleri silik olabilir; geniş beyin penceresinin yanında gri-beyaz cevher farkını belirginleştiren dar inme penceresini kullan.
• Posterior fossa ve küçük laküner infarktlar kontrastsız BT'de özellikle zor seçilir; normal görüntü şüpheyi sürdürüyorsa difüzyon MR gerekir.
• BTA'da hipoplastik A1/P1 veya vertebral arter varyantını akut oklüzyon sanma; distal devamlılığı, communicating arterleri ve damar alanı bulgularını birlikte izle.

Kendini dene

1. On dakika süren afazi düzelmiş; kontrastsız BT'de kanama ve belirgin hipodensite yok. En doğru çıkarım hangisidir?

   • İskemik olay dışlandı
   • BT küçük akut infarktı dışlayamaz
   • Kesin migren aurası
   • Eski infarkt kanıtlandı
   Cevabı göster

   BT küçük akut infarktı dışlayamaz. Erken veya küçük akut infarkt kontrastsız BT'de görünmeyebilir; semptomların düzelmesi de iskemik olayı dışlamaz. Migren tanısı yalnız görüntülemeyle konmaz, eski infarkt ise hacim kaybı ve ensefalomalazi gibi kronik bulgu gerektirir.

2. Geçici sağ kol güçsüzlüğü sonrası BTA'da sol M1 fokal daralmış ve distal dallar zayıf opak. BT'de erken iskemik değişiklikler görülmeyebileceğinden, bunları saptamak için hangi görüntüleme yöntemi daha duyarlıdır?

   • Difüzyon MR
   • Kemik penceresi
   • Sinüs BT
   • Kontrastsız boyun BT
   Cevabı göster

   Difüzyon MR. MR görüntülemenin küçük infarktları saptama duyarlılığı BT'den daha yüksektir; başlangıç BT'sinde infarkt görülmemesi inme olasılığını dışlamaz. Kemik ya da sinüs penceresi ve kontrastsız boyun BT'si beyin parankimindeki erken iskemiyi değerlendirmez.

İlgili konular

• İntrakraniyal arter diseksiyonu

Kaynaklar

Bu sayfadaki 38 cümle ve 2 quiz sorusu aşağıdaki kaynaklardan alıntılarla tek tek karşılaştırıldı; 8 cümle bu karşılaştırmada düzeltildi (2026-10-08).

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