{"id":3800,"date":"2023-02-13T13:25:15","date_gmt":"2023-02-13T13:25:15","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=3800"},"modified":"2023-02-23T17:25:11","modified_gmt":"2023-02-23T17:25:11","slug":"13-intraoperativna-prevencija-ishemije-mozga","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=3800","title":{"rendered":"13. INTRAOPERATIVNA PREVENCIJA ISHEMIJE MOZGA"},"content":{"rendered":"

\"\"
\n\"\"<\/a><\/p>\n

<\/p>\n

INTRAOPERATIVNA PREVENCIJA ISHEMIJE MOZGAa<\/h1>\n

<\/a><\/h1>\n

\n

Airplanes<\/i> <\/i>stay<\/i> <\/i>up<\/i> <\/i>only<\/i> <\/i>while<\/i> <\/i>they<\/i> <\/i>are<\/i> <\/i>in<\/i> <\/i>motion.
<\/i>J. Vollmar<\/em><\/p>\n

There<\/i> <\/i>is<\/i> <\/i>only<\/i> <\/i>one<\/i> <\/i>corner<\/i> <\/i>of<\/i> <\/i>the<\/i> <\/i>universe<\/i> <\/i>you<\/i> <\/i>can<\/i> <\/i>be<\/i> <\/i>certain<\/i> <\/i>of<\/i> <\/i>improving,<\/i> <\/i>an<\/i> <\/i>that<\/i> <\/i>is<\/i> <\/i>your<\/i> <\/i>own<\/i> <\/i>self.
<\/i>Aldous Huxley<\/em><\/p>\n<\/div>\n

\n

NTRAOPERATIVNA PREVENCIJA ISHEMIJE MOZGA<\/h2>\n

Klju\u010dni trenutak u razvoju karotidne hirurgije je kr\u0161enje jedne dogme. Klasi\u010dan stav je bio da perfuzija mozga ne sme da se prekine du\u017ee od tri minuta, ina\u010de se javljaju ireverzibilna o\u0161te\u0107enja neurona.<\/p>\n

Da bi se na\u010dinila rekonstrukcija karotidne arterije mora se privremeno obustaviti protok krvi kroz nju.<\/p>\n

Prve operacije na karotidnoj arteriji izvedene su bez protekcije mozga uz princip da vreme klemovanja bude \u0161to kra\u0107e. Me\u0111utim, problem<\/b> <\/b>cerebralne<\/b> <\/b>pro-<\/b> <\/b>tekcije<\/b> <\/b>tokom klemovanja karotidnih arterija je intrigirao vaskularne hirurge u poku\u0161ajima da karotidnu endarterektomiju u\u010dine \u0161to bezbednijom.<\/p>\n

Primenjivana je indukovana intraoperativna sistemska hipotermija, arterijska hipertenzija, hiperkarbija, hipokarbija itd. ali bez zna\u010dajnih rezultata.<\/p>\n

Ideja postavljanja privremenog protektivnog shunta koji bi tokom klemovanja arterija odr\u017eavao cerebralnu perfuziju realizovao je prvi put Cooley (1956), plasiranjem ekstraluminalne polivinilske cev\u010dice koja zaobilazi klemovani segment, ali stvara nove tehni\u010dke probleme pri plasiranju i ekstrakciji shunta, kao i zatvaranju arteriotomije. Mnogo prakti\u010dnijom pokazao se intraluminalni protektivni shunt, koji su uveli Javid i Thompson na osnovu sugestije od strane Stanley Crawford-a (1961).<\/p>\n

Intraluminalni<\/b> <\/b>shunt<\/b> <\/b>podrazumeva plasiranje polivinilske cev\u010dice, nakon arteriotomije, u distalni i proksimalni arteriski segment tako da je rekonstrukcija mogu\u0107a, a perfuzija mozga te\u010de nesmetano. Danas je u upotrebi vi\u0161e vrsta \u0161antova, a najsavremeniji je Pruitt-Inahara \u010dijom se upotrebno elimini\u0161e potreba za klemovanjem karotidnih arterije.<\/p>\n<\/div>\n

\"\"<\/p>\n

\n

Po\u010detak karotidne endarterektomije sa longitudinalnom arteriotomijom i distalnim odvajanjem karotidnog plaka koji \u0107e biti endarterektomisan.<\/em><\/em><\/p>\n<\/div>\n

\n
\n

Me\u0111utim, ubrzo se pokazalo da upotreba intraluminalnog shunta nije sasvim bezazlena, \u010dak i u rukama izuzetno ve\u0161tog hirurga, ona mo\u017ee dovesti do<\/p>\n

    \n
  • vazdu\u0161ne embolije (pucanje okluzivnog balona),<\/li>\n
  • (mikro)tromboembolije delovima tro\u0161nog plaka, prizidnim trombom itd,<\/li>\n
  • disekcije unutra\u0161nje karotidne arterije,<\/li>\n
  • endotelne lezije koja predisponira pojavu restenoze, osim toga<\/li>\n
  • \u0161ant mo\u017ee smetati pri endarterektomiji i fiksaciji distalnog kraja intime.<\/li>\n<\/ul>\n

    Danas je najvi\u0161e hirurga koji intraluminalni shunt koriste selektivno. Ipak, oni koji smatraju da shunt treba koristiti uvek, kao razlog navode: shunt smanjuje stres kod hirurga, shunt omogu\u0107ava du\u017ei i bezbedniji rad (tehni\u010dka perfekcija); upotrebom \u0161anta se elimini\u0161e opasnost od reperfuzionog sindroma i postoperativnog edema mozga.<\/p>\n

    Glavne indikacije za obaveznu primenu shunta su:<\/p>\n

      \n
    • raniji ipsilateralni preoperativni cerebrovaskularni insult,<\/li>\n
    • hemodinamski zna\u010dajno oboljenje druge karotidne i\/ili vertebralne arterije,<\/li>\n
    • ako se unapred zna da \u0107e klemovanje karotidne arterije suvi\u0161e dugo trajati.<\/li>\n<\/ul>\n

      Raniji<\/b> <\/b>ipsilateralni<\/b> <\/b>cerebralni<\/b> <\/b>inzult<\/b> <\/b>je (apsolutna) indikacija za primenu \u0161anta kako bi se spre\u010dilo reperfuziono o\u0161te\u0107enje mozga, u zoni koja je ledirana ranijim ishemi\u010dkim infarktom. Ishemi\u010dki infarkt u svom sredi\u0161tu ima zonu nekroze koja kasnije biva pro\u017eeta vezivnim i o\u017eiljnim tkivom. Ostaje sklonost za reinfarkciju ili akutizaciju starog insulta, a patogenetski mehanizam je:<\/h4>\n
        \n
      • hemoragija<\/span> <\/span>zbog<\/span> <\/span>slabosti<\/span> <\/span>lokalnih<\/span> <\/span>krvnih<\/span> <\/span>sudova,<\/span><\/li>\n
      • nova<\/span> <\/span>ishemija<\/span> <\/span>tokom<\/span> <\/span>klemovanja<\/span> <\/span>i\/ili<\/span> <\/span>(re)tromboze<\/span> <\/span>irigiraju\u0107ih<\/span> <\/span>arterija,<\/span><\/li>\n
      • kompresija<\/span> <\/span>edemom<\/span> <\/span>okolnog<\/span> <\/span>mo\u017edanog<\/span> <\/span>tkiva,<\/span><\/li>\n
      • ekscesivni<\/span> <\/span>postreperfuzioni<\/span> <\/span>edem<\/span> <\/span>u<\/span> <\/span>starom<\/span> <\/span>ishemi\u010dkom<\/span> <\/span>fokusu.<\/span><\/li>\n<\/ul>\n

        Zona<\/span> <\/span>postinfarktne<\/span> <\/span>nekroze<\/span> <\/span>te\u017ee<\/span> <\/span>podnosi<\/span> <\/span>oscilacije<\/span> <\/span>u<\/span> <\/span>perfuziji,<\/span> <\/span>a<\/span> <\/span>intraluminalni<\/span> <\/span>shunt<\/span> <\/span>bi<\/span> <\/span>trebalo<\/span> <\/span>da<\/span> <\/span>ih<\/span> <\/span>ubla\u017ei.<\/span> <\/span>Bolesnik<\/span> <\/span>mo\u017ee<\/span> <\/span>biti<\/span> <\/span>\u010dak<\/span> <\/span>i<\/span> <\/span>asimptomatski,<\/span> <\/span>ali<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>bilo<\/span> <\/span>ireverzibilnog<\/span> <\/span>o\u0161te\u0107enja<\/span> <\/span>mo\u017edanog<\/span> <\/span>tkiva<\/span> <\/span>po<\/span> <\/span>tipu<\/span> <\/span>infarkta,<\/span> <\/span>CT<\/span> <\/span>ili<\/span> <\/span>MRI<\/span> <\/span>mozga<\/span> <\/span>\u0107e<\/span> <\/span>ga<\/span> <\/span>detektovati<\/span> <\/span>(silent<\/span> <\/span>brain<\/span> <\/span>infarction).<\/span> <\/span>Dakle,<\/span> <\/span>kriterijum<\/span> <\/span>ovde<\/span> <\/span>ne<\/span> <\/span>bi<\/span> <\/span>trebalo<\/span> <\/span>da<\/span> <\/span>bude<\/span> <\/span>neurolo\u0161ki<\/span> <\/span>status,<\/span> <\/span>nego<\/span> <\/span>CT<\/span> <\/span>(MRI)<\/span> <\/span>nalaz.<\/span> <\/span>Ponekad<\/span> <\/span>se,<\/span> <\/span>CT-pozitivan<\/span> <\/span>nalaz<\/span> <\/span>otkriva<\/span> <\/span>u<\/span> <\/span>pacijenata<\/span> <\/span>sa<\/span> <\/span>TIA<\/span> <\/span>i<\/span> <\/span>asimptomatskih<\/span> <\/span>karotidnih<\/span> <\/span>stenoza.<\/span> <\/span>Zato<\/span> <\/span>je<\/span> <\/span>preoperativni<\/span> <\/span>CT<\/span> <\/span>pregled<\/span> <\/span>mozga<\/span> <\/span>uvek<\/span> <\/span>koristan.<\/span><\/p>\n

        Simultane<\/b><\/span> <\/b><\/span>lezije<\/b><\/span> <\/b><\/span>drugih<\/b><\/span> <\/b><\/span>arterija:<\/b><\/span> <\/b><\/span>Hemodinamski<\/span> <\/span>zna\u010dajna<\/span> <\/span>bolest<\/span> <\/span>druge<\/span> <\/span>karotidne<\/span> <\/span>i<\/span> <\/span>vertebralnih<\/span> <\/span>arterija<\/span> <\/span>je<\/span> <\/span>indikacija<\/span> <\/span>za<\/span> <\/span>primenu<\/span> <\/span>\u0161anta.<\/span> <\/span>Kod<\/span> <\/span>takvih<\/span> <\/span>bolesnika<\/span> <\/span>se<\/span> <\/span>ne<\/span> <\/span>mo\u017ee<\/span> <\/span>o\u010dekivati<\/span> <\/span>da,<\/span> <\/span>i<\/span> <\/span>ako<\/span> <\/span>je <\/span>Willis-ov<\/span> <\/span>\u0161estougao<\/span> <\/span>funkcionalan,<\/span> <\/span>perfuzija<\/span> <\/span>\u010ditavog<\/span> <\/span>mozga<\/span> <\/span>bude<\/span> <\/span>dobra,<\/span> <\/span>pri<\/span> <\/span>du\u017eem<\/span> <\/span>klemovanju.<\/span> <\/span>U<\/span> <\/span>nekim<\/span> <\/span>situacijama,<\/span> <\/span>kao<\/span> <\/span>\u0161to<\/span> <\/span>je<\/span> <\/span>izvo\u0111enje<\/span> <\/span>transpozicije,<\/span> <\/span>moraju<\/span> <\/span>se<\/span> <\/span>itovremeno<\/span> <\/span>klemovati<\/span> <\/span>dve<\/span> <\/span>arterije<\/span> <\/span>koje<\/span> <\/span>dovode<\/span> <\/span>krv<\/span> <\/span>do<\/span> <\/span>mozga<\/span> <\/span>(npr.<\/span> <\/span>karotidna<\/span> <\/span>i<\/span> <\/span>vertebralna),<\/span> <\/span>pa<\/span> <\/span>\u0107e<\/span> <\/span>ishemija<\/span> <\/span>biti<\/span> <\/span>intenzivnija.<\/span> <\/span>Ako<\/span> <\/span>se<\/span> <\/span>jo\u0161<\/span> <\/span>prethodno<\/span> <\/span>mora<\/span> <\/span>uraditi<\/span> <\/span>endarterektomija<\/span> <\/span>jedne<\/span> <\/span>ili<\/span> <\/span>dve<\/span> <\/span>arterije<\/span> <\/span>protekcija<\/span> <\/span>mozga<\/span> <\/span>je<\/span> <\/span>po\u017eeljnija.<\/span><\/p>\n

        O\u010dekivana<\/b><\/span> <\/b><\/span>du\u017eina<\/b><\/span> <\/b><\/span>trajanja<\/b><\/span> <\/b><\/span>klemovanja<\/b><\/span> <\/b><\/span>(rekonstrukcije)<\/span> <\/span>je<\/span> <\/span>vrlo<\/span> <\/span>bitan<\/span> <\/span>faktor<\/span> <\/span>u<\/span> <\/span>planiranju<\/span> <\/span>primene<\/span> <\/span>intraluminalnog<\/span> <\/span>shunta.<\/span> <\/span>Endarterektomija<\/span> <\/span>kratkog<\/span> <\/span>segmenta,<\/span> <\/span>homogenog<\/span> <\/span>i<\/span> <\/span>kalci<\/span>fi<\/span>kovanog<\/span> <\/span>plaka<\/span> <\/span>ne<\/span> <\/span>zahteva<\/span> <\/span>puno<\/span> <\/span>vremena.<\/span> <\/span>Duga\u010dke,<\/span> <\/span>multilokularne,<\/span> <\/span>heterogene<\/span> <\/span>arterioskleroti\u010dne<\/span> <\/span>lezije,<\/span> <\/span>kao<\/span> <\/span>i<\/span> <\/span>arteritis<\/span> <\/span>obi\u010dno<\/span> <\/span>zahtevaju<\/span> <\/span>dugotrajnije<\/span> <\/span>klemovanje.<\/span><\/p>\n

        Willis-ov<\/b><\/span> <\/b><\/span>\u0161estougao<\/b><\/span> <\/b><\/span>je<\/span> <\/span>kompletan<\/span> <\/span>u<\/span> <\/span>anatomsko-funkcionalnom<\/span> <\/span>smislu<\/span> <\/span>u<\/span> <\/span>samo<\/span> <\/span>50%<\/span> <\/span>slu\u010dajeva.<\/span> <\/span>Jasno<\/span> <\/span>je<\/span> <\/span>za\u0161to<\/span> <\/span>\u0107e<\/span> <\/span>bolesnici<\/span> <\/span>sa<\/span> <\/span>kompletnim<\/span> <\/span>Willis-ovim<\/span> <\/span>poligonom<\/span> <\/span>bolje<\/span> <\/span>tolerisati<\/span> <\/span>klemovanje<\/span> <\/span>karotidne<\/span> <\/span>arterije.<\/span> <\/span>Status<\/span> <\/span>Willis-ovog<\/span> <\/span>\u0161estougla<\/span> <\/span>se<\/span> <\/span>mo\u017ee<\/span> <\/span>preoperativno<\/span> <\/span>utvrditi<\/span> <\/span>MRI<\/span> <\/span>ili<\/span> <\/span>MSCT<\/span> <\/span>snimanjem.<\/span> <\/span>Najbitniji<\/span> <\/span>podatak<\/span> <\/span>je<\/span> <\/span>funkcionalnost<\/span> <\/span>ramus<\/span> <\/span>komunikans<\/span> <\/span>posterior<\/span> <\/span>(<\/span>ramus<\/i><\/span> <\/i><\/span>communicans<\/i><\/span> <\/i><\/span>posterior<\/i><\/span>),<\/span> <\/span>po\u0161to<\/span> <\/span>je<\/span> <\/span>njeno<\/span> <\/span>postojanje<\/span> <\/span>i<\/span> <\/span>prolaznost<\/span> <\/span>najproblemati\u010dnije,<\/span> <\/span>a<\/span> <\/span>najve\u0107i<\/span> <\/span>deo<\/span> <\/span>kompenzatornog<\/span> <\/span>protoka<\/span> <\/span>izme\u0111u<\/span> <\/span>prednje<\/span> <\/span>i<\/span> <\/span>zadnje<\/span> <\/span>mo\u017edane<\/span> <\/span>cirkulacije<\/span> <\/span>odvija<\/span> <\/span>se<\/span> <\/span>preko<\/span> <\/span>nje.<\/span><\/p>\n<\/div>\n

        \"\"<\/p>\n

        \n

        Plasiranje intraluminalnog shunt-a.<\/em>
        Proksimalna klema se za trenutak otvori da bi se shunt plasirao, bez krvarenja, a zatim se umesto kleme zate\u017ee tourniquet. Nakon ispiranja (flushing-a) se isti postupak ponavlja sa distalnim krajem shunt-a.<\/em><\/p>\n<\/div>\n

        \"\"<\/p>\n

        \n

        Nakon ispiranja (flushing-a) shunt funkcioni\u0161e.
        Vidi se velika ulceracija karotidnog plaka.<\/em><\/p>\n<\/div>\n

        \"\"<\/p>\n

        \n

        Uspostavljanje protektivnog privremenog shunt-a izme\u0111u ascendentne aorte i leve zajedni\u010dke karotidne arterije, u slu\u010daju da je neophodno (du\u017ee) klemovanje brahio-cefali\u010dkog trunkusa.<\/em><\/p>\n

        \u00a0<\/em><\/p>\n<\/div>\n


        \n<\/p>\n","protected":false},"excerpt":{"rendered":"

        INTRAOPERATIVNA PREVENCIJA ISHEMIJE MOZGAa Airplanes stay up only while they are in motion.J. Vollmar There is only one corner of the universe you can be certain of improving, an that is your own self.Aldous Huxley NTRAOPERATIVNA PREVENCIJA ISHEMIJE MOZGA Klju\u010dni trenutak u razvoju karotidne hirurgije je kr\u0161enje jedne dogme. Klasi\u010dan stav je bio da perfuzija […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-3800","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n13. INTRAOPERATIVNA PREVENCIJA ISHEMIJE MOZGA - KAROTIDNA HIRURGIJA<\/title>\n<meta name=\"description\" content=\"Klju\u010dni trenutak u razvoju karotidne hirurgije je kr\u0161enje jedne dogme. 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