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Onemocnění nervové soustavy

 Epilepsie, hydrocefalismus, klíšťatový zánět mozku, otřes mozku, kinetóza, Ischémie, infarkt myokardu, embolie, trombóza, anémie, oběhový kolaps, leukémie

Neuroinfekční onemocnění

Mezi neuroinfekce (encefalitidy, meningitidy) zahrnujeme mnoho akutních i chronických onemocnění. Mohou být virového i bakteriálního původu.

Nemoc postihuje buď nervovou tkáň samotnou, nebo obaly, popřípadě oboje. Téměř vždy jsou postiženy mozkové pleny (encefalomeningitida). Pokud jsou postiženy pleny, mozek, mícha, kořeny míšní, a nervy mluvíme o meningeoencefalomyelopolyradiculo-neuritidě.

Vstupní brána a šíření virů jsou různé. Některé se šíří čichovými drahami, jiné vegetativními vlákny a další hematogenně. Cesta bakteriální infekce CNS je většinou hematogenní. Přenašeči mohou být: klíště, mouchy, potraviny, nebo přímým kontaktem.

Virové onemocnění má tato stádia:        

·         Latentní stádium – virus pronikl do organismu, ale klinicky se neprojevuje. V tomto stádiu se tvoří protilátky a infikovaní jsou zdrojem nákazy.

·         Viremické stádium – projevuje se „chřipkovými příznaky”: teplota, bolest hlavy: malátnost, překrvení sliznic HCD a očních spojivek, někdy průjem. Virus proniká do krevního oběhu.

·         Intravalární stádium – (zdánlivého uzdravení), nemocný se cítí subjektivně dobře. Trvá několik dnů, týdnů i měsíc.

·         Neurální stádium – virus pronikl do mozku, popřípadě do míchy. Klinicky se projeví vzestupem teploty a ložiskovými příznaky (podle umístění).

 

Nervový systém může být při infekci organizmu postižen dvojím způsobem: jako primárně zánětlivé onemocnění vyvolané přímým působením infekčního agens, anebo jako nezánětlivé onemocnění, které se rozvíjí jako důsledek toxických, metabolických a cirkulačních poruch v nervovém systému. První skupina se označuje jako neuroinfekce, druhá jako toxoinfekční encefalopatie.

Neuroinfekce lze rozdělit podle různých kritérií. Podle lokalizace se rozdělují na: infekce CNS: meningitidy (záněty mozkomíšních plen), encefalitidy (záněty mozku) a myelitidy (záněty míchy),

infekce periferního nervového systému: radikulitidy (záněty nervových kořenů) a neuritidy (záněty periferních nervů). Obvykle však zánět není omezen na jeden orgán či strukturu, a tak vznikají meningo-encefalitidy, encefalomyelitidy apod.

Důležité rozdělení neuroinfekcí vychází z charakteru zánětlivé odpovědi. Podle toho se záněty nervového systému - zvláště meningitidy - rozdělují na:

·         hnisavé (purulentní) - jsou vyvolány bakteriemi, houbami a prvoky

·         nehnisavé (serózní, aseptické, lymfocytární) – vyvolány viry a spirochétami

·         specifické (granulomatózní) – vyvolány např. mykobakteriem tuberkulózy

 

Pro meningitidu velmi charakteristickým, i když ne zcela specifickým příznakovým souborem je meningeální syndrom. Omezení flekčních pohybů páteře v důsledku stahu paravertebrálního svalstva: váznutí šíje, Brudzinského příznak, spinální znamení, příznak trojnožky atd. Vedle bolestí hlavy a meningeálních příznaků jsou dalšími symptomy horečka a v důsledku mozkového edému i poruchy vědomí a chování.

Rozhodující význam v diagnostice neuroinfekcí má vyšetření mozkomíšního moku.

 

Tetanus

Tetanus (strnutí šíje) je raná infekce způsobená neurotoxinem anaerobní mikroba Clostridium tetani. Díky očkování a řádnému ošetření kontaminovaných zranění je onemocnění vzácné. Typickými projevy nemoci je zvýšené napětí až křeče kosterních svalů. Iniciálním příznakem je trismus – nemožnost rozevřít ústa. Stav pacienta zvláště ohrožují poruchy vegetativní regulace. Prognóza je vážná: pacient může zemřít v křeči dýchacího svalstva, poruchou dýchání z poškození dechového centra, srdečním selháním či arytmií. Základem léčby je klid, podání globulinu, penicilinu a antikonvulziv.

 

 

Cévní onemocnění CNS - Dělí se na pomalu vnikající (arterioskleróza) a náhle vznikající (CMP)

 

Cévní mozková příhoda

CMP je porucha v prokrvení mozkové tkáně. Z 80% jde většinou o ischemickou formu, kdy je přerušen nebo omezen přísun krve k buňkám. Ve zbylých procentech se jedná o formu hemoragickou (krvácivou) nebo smíšenou.

Mozek je zásobován ze dvou základních párových cév. Karotické a vertebrobasilární řečiště. Krkavice se dělí na vnější (externa) a vnitřní (interna), která je hlavním zdrojem zásobení přední a střední části mozku. Aa. vertebrales vstupují velkým otvorem do lebky a zde se spojují v a. basilaris a zásobují hlavně zadní část mozku, mozeček, mozkový kmen a části mezimozku. Projevy CMP závisí na poškozené oblasti. Jelikož se některé nervové dráhy kříží, při poškození struktur v pravé hemisféře mozku dochází k projevům na druhostranných končetinách a naopak. Nejtypičtějším obrazem, který známe, bývá paréza až plegie (ochrnutí) jednostranné horní či dolní končetiny s poklesem ústního koutku a se ztrátou vnímání tepla, doteku či bolesti.

 

Epilepsie

Záchvat je výsledkem chorobného dráždění mozku, který se šíří z určitého ohniska.

Jde o porušení funkce mozkových gangliových buněk. Důležitou roli hrají dědičné dispozice (vyvolávajícími faktory mohou být spánková deprivace, stres, ostré světlo, poruchy prokrvení, nádory, toxické látky. Sekundární epilepsie vzniká z předchozího poškození mozku. Jsou dva druhy záchvatů: Grand mal a Petit mal

Grand mal trvá 1- 3 min, začíná náhle bezvědomím a pádem na zem. Záchvat provázený tonicko-klonickými křečemi se zástavou dechu a ztrátou vědomí. Záchvatu mohou předcházet subjektivní pocity tzv. aura (čichové, zrakové, chuťové vjemy). Po 10 nebo více sekundách dochází k rozvoji generalizovaných klonických záškubů. Z úst vystupuje pěna, mnohokrát dojde k pokousání jazyka a spontánnímu odchodu moče a stolice. Klonické záškuby mohou trvat až několik minut a bývají spojeny s následným bezvědomím. Často se postižený při záchvatu pomočí, pokouše si jazyk atd. Po záchvatu se vyskytuje amnézie na vlastní záchvat, zmatenost, velká únava, bolest hlavy, ospalost. Časté záchvaty mohou vést ke změně osobnosti.

Petit mal je nejčastěji u mladých. Je charakterizován náhlou, velmi krátkou poruchou vědomí (asi sekundu nebo několik sekund) takže postižený ani neupadne. Pacient se např. zahledí do prázdna a po odeznění se věnuje předchozí činnosti. Toto se nazývá absence. Jedná se o řadu epileptických projevů ze skupiny generalizovaných záchvatů, které vykazují krátkodobou poruchu vědomí a žádné pády, nemusí být provázeny motorickými příznaky, případně anomáliemi svalového napětí.

Status epilepticus je stav kdy se hromadí GM záchvaty tak, že pacient ani nenabude vědomí mezi nimi. Jedná se o sled velkých záchvatů, které se mohou projevovat i izolovanými kontrakcemi svalů či svalových skupin. Jedná se o život ohrožující stav, který prostřednictvím centrální hypertermie, aspirace, poruchy elektrolytů a hypoxické nekrózy mozku vede nakonec ke smrti.

Komplikace – poranění hlavy, při statu epi – dechové poruchy, narůstá otok mozku, vyčerpání organismu.

PP -  zabránit pádu a dalšímu poranění, dýchací cesty uvolníme pouze správnou polohou., Diazepam i.v. do přerušení křečí, Uvolnění DC, podání O2, event. ŘV

 

Křeče jsou mimovolné svalové stahy objevující se častěji v záchvatech. Typy křečí:

Klonické – škubavé: vzteklina, otrava organofosfáty, hypoglykemie

Tonické – napětí svalstva: tetanus, otrava strychninem, hypokalcémie,

Tonicko-klonické – nejčastěji: epilepsie

 

 

Krvácení do míchy - hematomyelie

Je to náhlá cévní příhoda, kdy dochází ke krvácení do míšní tkáně z prasklé cévy. Je to méně časté onemocnění. Může vzniknout i při prudké a velké tělesné námaze. Předpokladem je chorobná změna cévních stěn. Příznaky se liší podle lokalizace.

 

Hydrocefalismus po toxoplazmóze

Termín hydrocefalus pochází z řečtiny: hydro = voda, kephale = hlava a znamená zvýšenou akumulaci tekutin (mozkomíšního moku) v dutinách mozku - mozkových komorách. Celkové množství moku v komorách a subarachnoidálních prostorech u dospělého se obměňuje třikrát za den. Od místa tvorby do místa vstřebávání musí mozkomíšní mok projít celým komorovým systémem mozku. Průtok moku může být narušen v kterémkoliv místě systému – v případě překážky hovoříme o obstrukčním hydrocefalu. Pokud je porucha až v místě vstřebávání (resorpce), mluvíme o hyporesorpčním hydrocefalu.

 

Klíšťový zánět mozku

Klíšťový zánět mozku a mozkových blan je zánětlivé onemocnění CNS, jehož původcem je virus ze skupiny arbovirů, přenášený klíštětem. Pes může být napaden larvou, nymfou i plně vyvinutým klíštětem. Infekce se šíří především přisátím infikovaného klíštěte, ale může k ní dojít i při požití mléka infikovaných zvířat, nejčastěji koz.

Klíšťová meningoencefalitida je typická nákaza s přírodní ohniskovostí, to znamená, že její výskyt je vázán na přírodní lokality. Rizikovými oblastmi jsou většinou listnaté nebo smíšené lesy v nižších polohách. Pro výskyt onemocnění je typická sezónnost, související s cyklem aktivity klíšťat.

Inkubační doba (od přisátí klíštěte ke vzniku prvních příznaků onemocnění) trvá 7 - 14 dnů. Typické onemocnění probíhá ve dvou fázích: v prvé fázi se objevují horečky, bolesti hlavy, malátnost, nevolnost, bolesti v kloubech. Tato fáze trvá 4 - 15 dnů. Toto stadium je někdy nevýrazné. Druhá fáze nastupuje po několikadenním (8 -15 dny klidovém období, kdy se nemocný cítí lépe. Poté se objeví opět horečky a v různé intenzitě příznaky postižení CNS: bolest hlavy, zvracení, meningeální příznaky (tuhost svalstva šíje), poruchy paměti, dezorientace, poruchy spánku, svalový třes, závratě, obrny nervů. Po prožití onemocnění mohou přetrvávat obrny (parézy) nebo dlouhotrvající drobné neurologické poruchy. Nepříjemným a někdy dlouhotrvajícím následkem bývají např. poruchy spánku, schopnost soustředit se, lability, nálady apod. Bez následků bývají především formy s menším rozsahem postižení mozku (forma meningeální). Ochrana - Postříkání repelentními a insekticidními přípravky (Diffusil V) nebo Autan. Klíště odstraňujeme v rukavicích, protože potřísnění drobných oděrek na kůži obsahem např. přetrženého klíštěte může vést k přenosu nákazy. U dříve doporučovaného točení klíštětem ve směru hodinových ručiček hrozí rovněž přetržení klíštěte. Potření přisátého klíštěte tukem nebo olejem nemá odborné opodstatnění. Na přisáté klíště přiložíme vatu namočenou do Jodisolu nebo jodové tinktury, což zabezpečí dezinfekci rány, tak usmrcení klíštěte. Velmi důležité je provedení dezinfekce kůže, např. Jodisolem event. Jodonalem B jak před, tak i po odstranění klíštěte. Nejúčinnější ochranou proti onemocnění klíšťovým zánětem mozku je aktivní imunizace - očkování. Očkovací látka obsahuje mrtvý, tzv. inaktivovaný virus, který se nemůže v organizmu pomnožit.

 

Otřes mozku

Poranění hlavy - Pod pojmem kraniocerebrální poranění rozumíme tři typy úrazů:

1.    poranění měkkých tkání

2.    poranění lebky – zlomeniny

3.    poranění mozku - dřívější dělení:

·         komoce (otřes)

·         kontuze (zhmoždění)

·         komprese (stlačení, poranění, kdy krev stlačí mozk. tkáň rozvijí se nitrolební hypertenze)

Nyní rozlišujeme postižení:

·         Difuzní -komoce mozková, difuzní axonové poranění (DAP),swelling

·         Ložiskové -mozkové kontuze

·         Kompresivní -nitrolební krvácení:hematomy epidurální, subdurální (akutní, subakutní), intracerebrální, subdurální hydrom

Otřes mozku (komoce) - patří mezi lehčí poranění, kdy nedochází k žádným morfologickým změnám, pouze dojde k přechodným funkčním příznakům. Bývá to krátkodobé bezvědomí, retrográdní amnezie (ztráta paměti vztahující se na časový úsek před úrazem hlavy, otřesem mozku, komatem), zvracení, bolest hlavy, závrať, únava, dezorientace či poruchy spánku.  V PNP počítat s poraněním C obratlů!

 Komoce mozku se léčí klidem, ledovými obklady, podáváním analgetik a sedativ. Je třeba sledovat vědomí, tlak, puls a dech. Důležitá je kontrola nitrolebního tlaku, který se může začít zvyšovat při opožděném nitrolebním krvácení.

  

Kinetóza

Kinetóza nebo také nemoc z pohybu je fyzický stav jedince, kdy vjem pohybu vestibulárním systémem nesouhlasí s vizuálními vjemy. Příznakem kinetózy může být závrať, vyčerpání či zvedání žaludku. Podle příčin vedoucích ke kinetóze se zpravidla mluví o mořské nemoci, nevolnosti v autě/autobuse, nevolnosti v letadle.

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