Biokemijski pokazatelji cerebralne ishemije i vazospazma u bolesnika liječenih zbog cerebralne aneurizme

doctoral thesis

• Author: Jelena Radonić; VIAF: 305533732
• Mentor: Ljiljana Popović (mentor)
• Committee member: nije dostupno (član povjerenstva)
• Granter: University of Zagreb; School of Medicine; Zagreb
• Defense date and country: 2015-05-18, Croatia
• Scientific / art field, discipline and subdiscipline: BIOMEDICINE AND HEALTHCARE; Clinical Medical Sciences
• Universal decimal classification (UDC): 61 - Medical sciences

Abstract

Cerebralni vazospazam u bolesnika s rupturom aneurizme i razvojem
subarahnoidalnog krvarenja može dovesti do naknadne cerebralne ishemije i
neuroloških oštećenja. Biomarkeri koji bi mogli predskazati pojavu
cerebralnog vazospazma i odložene cerebralne ishemije, te predskazati ishod
bolesnika mogli bi biti korisni u svakodnevnom radu.
U ovoj kliničkoj prospektivnoj studiji u bolesnika anesteziranih radi operacije
cerebralne aneurizme zabilježeni su relevantni klinički parametri i mjerene
koncentracije endotelina-1, laktata, parcijalni tlak kisika i ugljikovog dikosida te
saturacija hemoglobina kisikom od indukcije u anesteziju, za vrijeme i nakon
operacijskog zahvata. Provedena je analiza navedenih biokemijskih
parametara radi uvida u njihovu prediktivnu sposobnost pojave odložene
cerebralne ishemije uslijed vazospazma i ishoda bolesnika.
U studiju je uključen 41 bolesnik u kojeg je u općoj anesteziji učinjen
operacijski zahvat radi aneurizme cerebralne arterije. U 23 bolesnka
operacijski zahvat je učinjen nakon što je aneurizma rupturirala što je dovelo
do subarahnoidalnog krvarenja, a u 18 bolesnika operacijski zahvat je učinjen
u bolesnika u kojih nije bilo rupture aneurizme. U bolesnika operiranih nakon
rupture aneurizme prosječni GCS iznosio je 14.2, a Hunt Hess skor 1.48, dok
je u skupini bolesnika bez rupture aneurizme stanje svijesti bilo normalno.
Svi bolesnici su preživjeli. U 9 bolesnika zaostale su nakon zahvata i nakon 6
mjeseci praćenja neurološke posljedice, u 5 bolesnika blaže, a u 4 znatne.
Dvoje bolesnika imalo je u periodu nakon operacije epileptičke napade. Nije
bilo značajne razlike u ishodu bolesnika operiranih radi aneurizme koja je
rupturirala i onih u kojih nije bilo rupture aneurizme prije operacijskog zahvata.
Kliničkim praćenjem stanja svijesti predviđen je cerebralni vazospazam u 51.2
% bolesnika. Nije bilo statistički značajne razlike u učestalosti klinički
manifestnog spazma između skupine bolesnika operiranih radi rupturirane i
radi neurpturirane aneurizme.
Koncentracija endotelina-1, laktata, pO2 i pCO2 u arterijskoj krvi, te krvi iz
bulbusa jugularne vene, te njihova venoarterijska razlika nije se razlikovala
između skupine bolesnika s povoljnim i onih s nepovoljnim ishodom. Nalazi se
jedino statistički značajna razlika venoarterijske razlike endotelina u bolesnika
iduće jutro nakon operacijskog zahvata između onih s povoljnim i onih s
nepovoljnim neurološkim ishodom.
Osim toga, nalazi se visokoznačajna povezanost koncentracije endotelina-1 i
koncentracije laktata što upućuje na njihovo uključenje u patofiziološkom
zbivanju u ovih bolesnika.
Zanimljivo je i opažanje nižeg pCO2 u fazi nakon operacije, kad bolesnici
počnu ponovo spontano regulirati veličinu plućne ventilacije, u bolesnika s
nižim inicijalnim GCS i višim Hunt Hess skorom.
Možemo zaključiti da se endotelin-1 i drugi mjereni biokemijski parametri nisu
pokazali kao upotrebljivi klinički prediktori vazospazma i neurološkog ishoda u
bolesnika anesteziranih radi operacije cerebralne aneurizme, no postoji
njihova povezanost što upućuje na njihovu ulogu u jedinstvenom
patofiziološkom procesu u ovih bolesnika.

Abstract (english)

Cerebral vasospasm in patients with ruptured cerebral aneurysm and
development of subarachnoid haemorrhage may cause delayed cerebral
ishaemia and neuronal lesions. Potential biomarkers for prediction of
vasospasm and delayed cerebral ishemia could be helpful.
In this clinical prospective study endothelin-1, lactate, pCO2, pO2 and
haemoglobin oxygen saturation were measured in arterial blood and venous
blood obtained from internal jugular vein before, during and after surgery and
tested as potential predictors for delayed cerebral ischemia and neurologic
patients outcome.
41 patient, operated in general anesthesia due to cerebral aneurysm, was
enrolled in the study. In 23 patients surgery was performed after aneurysmal
rupture with development of subarachnoid hemorrhage (SAH). 18 were
operated due to nonruptured cerebral aneurysm. In patients with SAH
average Glasgow Coma Score (GCS) was 14.2 and Hunt Hess score was
1.48. Patients with nonruptured aneurysm didn't show disturbances of
consciousness before the treatment.
All patients survived. In 9 patients after the surgery and 6 month later
neurologic deficit was recorded, in 5 of them mild and in 4 significant. Two
patients experienced seizures during the follow up. There was no difference in
outcome between those operated after the SAH or those with nonruptured
aneurysm. Symptomatic vasospasm was recorded in 51.2% of patients, with
no statistically significant difference between groups of patients with or without
SAH.
Endothelin-1 and lactate concentrations as well as pO2 i pCO2 in arterial
blood and blood obtained from jugular vein and its venoarterial difference
didn't differ in group of patients according to neurologic outcome. Only
statistically significant was the difference between groups with favorable and
unfavorable neurologic oucome in venoarterious difference of endothelin-1
concentrations next day after surgery. Also, significant correlation between
endotheli-1 and lactate concentration was demonstrated, which suggest its
participation in the common patophysiologic process.
Interesting observation is the finding of lower pCO2 in patients with lower
initial GCS and higher Hunt Hess score in the phase after extubation, when
the patients breathe independently again so the amount of lung ventilation is
controlled spontaneously.
We can conclude that endothelin-1 and other measured biochemical
parameters didn't show enough predictive power to be useful in clinical
practice for prediction of cerebral vasospasm and neurologic outcome. But,
some correlation between them exists which suggest its enrolment in the
same patophysiologic process.

• Keywords: medicina
• Keywords (english): medicine
• Language: croatian
• URN:NBN: urn:nbn:hr:105:640860
• Study programme: Title: Biomedicine and Health Sciences; Study programme type: university; Study level: postgraduate; Academic / professional title: doktor/doktorica znanosti, područje biomedicine i zdravstva (doktor/doktorica znanosti, područje biomedicine i zdravstva)
• Type of resource: Text
• Extent: 166 str.
• File origin: Born digital
• Access conditions: Open access
• Created on: 2023-05-05 07:31:58