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ANEURISMAS INTRACRANIANOS – HSA
QUANDO OPERAR?
EARLY VERSUS DELAYED SURGERY
Dr. Marcelo Nery [email protected] – HH - 2008
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDE
1. RISCO DE MORTE E/OU DETERIORAÇÃO CONTINUA APÓS EVENTO INICIAL
• RESSANGRAMENTO E DIND
3. COMPLICAÇÕES CLÍNICAS E CIRÚRGICAS
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDE
TIMING
“THE DECISION OF WHETHER OR NOT TO PERFORM SURGERY ACUTELY AFTER SAH STRONGLY AFFECTS THE ABILITY TO PREVENT OR TREAT SOME OF THESE DEADLY COMPLICATIONS”
Kassel NF, Drake CG. Timing of aneurysm surgery. Neurosurgery 10:514-519, 1983
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDE
► QUESTÕES IMPORTANTES
• Por que discutir timing numa era de conflitos entre coiling/stenting e clipping?
• Existem estudos que evidenciem a superioridade dos resultados?
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDE
Operar agudamente com um cérebro edemaciado
versus
Esperar quando os efeitos da hemorragia inicial declinarem
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ANEURISMAS INTRACRANIANOS HEMORRAGIA SUBARACNÓIDE
História. 1938. Dandy (early)
. 1953. Norlen e Olivecrona (late)
.70. Sundt, Fischer, Suzuki (early)
.1980. ISTAS – International Study on the timing of aneurysm surgery
Prospective, observational, epidemiologic
survey
Kassel NF, Torner JC, Haley EC Jr. The International Cooperative Study on the Timing of Aneurysm Surgery. I: Overall management results.
J Neurosurg 73:18-36,1990
Kassel NF, Torner JC, Haley EC Jr. The International Cooperative Study on the Timing of Aneurysm Surgery. II: Surgical results. J of
Neurosurg 73:37-47,1990
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDEISTAS – overall results
► CIRURGIA NO PERÍODO DO DIA 7 A 10 PÓS HSA – EVOLUÇÃO MENOS FAVORÁVEL E MORTALIDADE SUPERIOR
► INCIDÊNCIA DE DÉFICIT POR ISQUEMIA POR DIND FOI > NO
GRUPO DO PERÍODO INTERMEDIÁRIO E TARDIO
► HIDROCEFALIA MAIOR NO GRUPO DO PERÍODO TARDIO
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDEISTAS – overall results
► MORTALIDADE NO GRUPO DO PERÍODO TARDIO DECORRENTE DE EVENTOS RELACIONADOS COM A ESPERA IGUAL A MORTALIDADE OPERATÓRIA DO GRUPO PRECOCE
► DIFICULDADES TÉCNICAS SIMILARES NO GRUPO TARDIO E
PRECOCE APESAR DO CÉREBRO EDEMACIADO
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ANEURISMAS INTRACRANIANOSHEMORRAGIA SUBARACNÓIDE
“Informações recentes não demonstram superioridade de resultados entre cirurgia precoce e cirurgia tardia especialmente em pacientes classificados como grupos 4 e 5”
Gans K, Nieuwkamp D. J., Rinkel G.J.E., Algra A.Timing of Aneurysm Surgery in Subarachnoid Hemorrhage:A Systematic Review of the
Literature. Neurosurgery 50(2);336-42,2002
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1010
ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDESeleção de pacientes para cirurgia
tardia
• Aneurisma da bifurcação ou tronco da basilar
• Aneurismas de angioarquitetura considerada difícil (e.g.: gigantes, colo largo)
• Presença de inchaço cerebral intenso• Presença de instabilidade neurológica
inicial• Idade superior a 60 anos• Dificuldades na logística (“qualified
team”, “referring”)
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ANEURISMAS INTRACRANIANOS
HEMORRAGIA SUBARACNÓIDEReferências bibliográficas principais
1. Lanzino G, Kassel NF. Surgical treatment of the ruptured aneurysm. Timing. Current Management
of cerebral aneurysms, part I: evaluation and perioperative care. Neurosurg Clin North Am 9
(3);541-8,1998
2. Shucart W, Wu J. Timing of operation for ruptured aneurysms: delayed surgery. Concepts in
Neurosurgery 6. CNS, 2006
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CIDADE SOL