{"id":4316,"date":"2023-02-15T13:09:48","date_gmt":"2023-02-15T13:09:48","guid":{"rendered":"https:\/\/www.karotidnahirurgija.com\/?page_id=4316"},"modified":"2023-02-24T09:27:06","modified_gmt":"2023-02-24T09:27:06","slug":"18-1-intraoperativni-mozdani-udar","status":"publish","type":"page","link":"https:\/\/www.karotidnahirurgija.com\/?page_id=4316","title":{"rendered":"18.1. INTRAOPERATIVNI MO\u017dDANI UDAR"},"content":{"rendered":"

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

<\/p>\n

KOMPLIKACIJE U KAROTIDNOJ HIRURGIJI<\/h1>\n

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

\n

18.1. INTRAOPERATIVNI\u00a0 I RANI POTOPERATIVNI MO\u017dDANI UDAR<\/h2>\n<\/h1>\n
\n

INTRAOPERATIVNI MO\u017dDANI UDAR<\/h3>\n

Uzrok mo\u017ee biti:<\/p>\n

    \n
  • ishemija<\/span> <\/span>mozga<\/span> <\/span>tokom<\/span> <\/span>klemovanja<\/span> <\/span>arterija<\/span> <\/span>ili<\/span><\/li>\n
  • embolizacija<\/span> <\/span>mozga<\/span> <\/span>tokom<\/span> <\/span>disekcije<\/span> <\/span>arterije<\/span> <\/span>sa<\/span> <\/span>ulcerisanim<\/span> <\/span>ateromom,<\/span> <\/span>tokom<\/span> <\/span>plasiranja<\/span> <\/span>intraluminalnog<\/i><\/span> <\/i><\/span>shunt<\/i><\/span>-a,<\/span> <\/span>klemovanja<\/span> <\/span>emboligenog<\/span> <\/span>ateroma,<\/span> <\/span>ili<\/span><\/li>\n
  • \n

    intraoperativna<\/span> <\/span>tromboza<\/span> <\/span>operisanog<\/span> <\/span>arterijskog<\/span> <\/span>segmenta,<\/span> <\/span>na<\/span> <\/span>bazi<\/span> <\/span>tehni\u010dke gre\u0161ke<\/span> <\/span>(iregularna<\/span> <\/span>suturna<\/span> <\/span>linija,<\/span> <\/span>lezije<\/span> <\/span>intime<\/span> <\/span>zbog<\/span> <\/span>intraluminalne<\/span> <\/span>dilatacije<\/span> <\/span>itd.).<\/span><\/p>\n<\/li>\n<\/ul>\n

    Re\u0111e<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>o<\/span> <\/span>intracerebralnoj<\/span> <\/span>hemoragiji<\/span> <\/span>(hipertenzija),<\/span> <\/span>ili<\/span> <\/span>drugim<\/span> <\/span>uzrocima<\/span> <\/span>koji<\/span> <\/span>nisu<\/span> <\/span>u<\/span> <\/span>vezi<\/span> <\/span>sa<\/span> <\/span>rekonstruisanim<\/span> <\/span>arterijskim<\/span> <\/span>segmentom.<\/span><\/p>\n

    Precizan<\/span> <\/span>po\u010detak<\/span> <\/span>i<\/span> <\/span>uzrok<\/span> <\/span>intraoperativnog<\/span> <\/span>neurolo\u0161kog<\/span> <\/span>de<\/span>fi<\/span>cita<\/span> <\/span>je<\/span> <\/span>te\u0161ko<\/span> <\/span>utvrditi<\/span> <\/span>ako<\/span> <\/span>se<\/span> <\/span>radi<\/span> <\/span>u<\/span> <\/span>op\u0161toj<\/span> <\/span>anesteziji.<\/span> <\/span>Upotreba<\/span> <\/span>regionalne<\/span> <\/span>anestezije<\/span> <\/span>i<\/span> <\/span>intraoperativni<\/span> <\/span>monitoring<\/span> <\/span>(transkranijalni<\/span> <\/span>doppler,<\/span> <\/span>elektroencefalogra<\/span>fi<\/span>ja<\/span> <\/span>itd.)<\/span> <\/span>ukazuju<\/span> <\/span>na<\/span> <\/span>prirodu<\/span> <\/span>intraoperativne<\/span> <\/span>cerebralne<\/span> <\/span>ishemije.<\/span> <\/span>Kod<\/span> <\/span>operacija<\/span> <\/span>u<\/span> <\/span>regionalnoj<\/span> <\/span>anesteziji<\/span> <\/span>(budan<\/span> <\/span>pacijent)<\/span> <\/span>incident<\/span> <\/span>obi\u010dno<\/span> <\/span>po\u010dinje<\/span> <\/span>pri<\/span> <\/span>disekciji<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>sa<\/span> <\/span>ulcerisanim<\/span> <\/span>plakom<\/span> <\/span>ili<\/span> <\/span>prilikom<\/span> <\/span>pu\u0161tanja<\/span> <\/span>kleme<\/span> <\/span>sa<\/span> <\/span>uspostavljanjem<\/span> <\/span>cirkulacije.<\/span> <\/span>Tehni\u010dki<\/span> <\/span>problemi<\/span> <\/span>se<\/span> <\/span>najbolje<\/span> <\/span>detektuju<\/span> <\/span>intraoperativnom<\/span> <\/span>Duplex-sonogra<\/span>fi<\/span>jom<\/span> <\/span>ili<\/span> <\/span>arterio-<\/span> <\/span>gra<\/span>fi<\/span>jom<\/span> <\/span>nakon<\/span> <\/span>zavr\u0161etka<\/span> <\/span>rekonstrukcije,<\/span> <\/span>a<\/span> <\/span>pre<\/span> <\/span>zatvaranja<\/span> <\/span>operativnog<\/span> <\/span>polja.<\/span><\/p>\n

    Ako<\/span> <\/span>se<\/span> <\/span>pacijent<\/span> <\/span>probudi<\/span> <\/span>sa<\/span> <\/span>neurolo\u0161kim<\/span> <\/span>de<\/span>fi<\/span>citom<\/span> <\/span>nalazimo<\/span> <\/span>se<\/span> <\/span>u<\/span> <\/span>ekstremno<\/span> <\/span>urgentnoj<\/span> <\/span>situaciji.<\/span> <\/span>Odluka<\/span> <\/span>o<\/span> <\/span>reoperaciji<\/span> <\/span>mora<\/span> <\/span>vrlo<\/span> <\/span>brzo<\/span> <\/span>biti<\/span> <\/span>donesena,<\/span> <\/span>a<\/span> <\/span>dijag-<\/span> <\/span>nosti\u010dke<\/span> <\/span>mogu\u0107nosti<\/span> <\/span>su<\/span> <\/span>male.<\/span> <\/span>Rani<\/span> <\/span>kontrolni<\/span> <\/span>Duplex-sonografski<\/span> <\/span>pregled,<\/span> <\/span>nakon<\/span> <\/span>zatvaranja<\/span> <\/span>ko\u017ee,<\/span> <\/span>je<\/span> <\/span>neprecizan<\/span> <\/span>zbog<\/span> <\/span>lokalnog<\/span> <\/span>postoperativnog<\/span> <\/span>otoka,<\/span> <\/span>hematoma<\/span> <\/span>i<\/span> <\/span>mehuri\u0107a<\/span> <\/span>vazduha<\/span> <\/span>u<\/span> <\/span>tkivu<\/span>1,4<\/span><\/sup>.<\/span> <\/span>Kontrolna<\/span> <\/span>arteriogra<\/span>fi<\/span>ja<\/span> <\/span>se<\/span> <\/span>ne<\/span> <\/span>mo\u017ee<\/span> <\/span>urediti<\/span> <\/span>za<\/span> <\/span>manje<\/span> <\/span>od<\/span> <\/span>15<\/span> <\/span>min.<\/span> <\/span>Sli\u010dno<\/span> <\/span>je<\/span> <\/span>i<\/span> <\/span>sa<\/span> <\/span>CT-om<\/span> <\/span>mozga<\/span> <\/span>koji<\/span> <\/span>pri<\/span> <\/span>tome<\/span> <\/span>ne<\/span> <\/span>daje<\/span> <\/span>prikaz<\/span> <\/span>stanja<\/span> <\/span>operisane<\/span> <\/span>arterije.<\/span><\/p>\n

    Razlozi<\/span> <\/span>za<\/span> <\/span>pojavu<\/span> <\/span>intraoperativnog<\/span> <\/span>mo\u017edanog<\/span> <\/span>udara<\/span> <\/span>mogu<\/span> <\/span>biti:<\/span> <\/span>(1)<\/span> <\/span>takvi<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>mogu<\/span> <\/span>korigovati<\/span> <\/span>i<\/span> <\/span>(2)<\/span> <\/span>takvi<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>ne<\/span> <\/span>mogu<\/span> <\/span>korigovati<\/span> <\/span>reparacijom<\/span> <\/span>arterije.<\/span> <\/span>Intraoperativni<\/span> <\/span>\u0161log<\/span> <\/span>za<\/span> <\/span>razliku<\/span> <\/span>od<\/span> <\/span>ranog<\/span> <\/span>postoperativnog<\/span> <\/span>\u010desto<\/span> <\/span>je<\/span> <\/span>embolijske<\/span> <\/span>i\/<\/span> <\/span>ili<\/span> <\/span>hemoragijske<\/span> <\/span>geneze.<\/span> <\/span>Zato<\/span> <\/span>ovde<\/span> <\/span>treba<\/span> <\/span>dvaput<\/span> <\/span>razmisliti<\/span> <\/span>i<\/span> <\/span>insistirati<\/span> <\/span>na<\/span> <\/span>brzoj<\/span> <\/span>dijagnostici<\/span> <\/span>(kontrolna<\/span> <\/span>arteriogra<\/span>fi<\/span>ja<\/span> <\/span>u<\/span> <\/span>roku<\/span> <\/span>od<\/span> <\/span>15<\/span> <\/span>minuta).<\/span> <\/span>Ako<\/span> <\/span>je<\/span> <\/span>intraoperativna<\/span> <\/span>embolizacija<\/span> <\/span>ili<\/span> <\/span>intraoperativna<\/span> <\/span>ishemija<\/span> <\/span>razlog<\/span> <\/span>lezije<\/span> <\/span>mozga<\/span> <\/span>reoperacija<\/span> <\/span>ne\u0107e<\/span> <\/span>ni\u0161ta<\/span> <\/span>popraviti.<\/span><\/p>\n<\/div>\n

    \n
    \n

    Rani postoperativni
    mo\u017edani udar<\/h3>\n

    <\/b><\/span>Pacijent<\/span> <\/span>se<\/span> <\/span>budi<\/span> <\/span>neurolo\u0161ki<\/span> <\/span>intaktan<\/span> <\/span>a<\/span> <\/span>zatim<\/span> <\/span>tokom<\/span> <\/span>naredna<\/span> <\/span>tri<\/span> <\/span>dana<\/span> <\/span>u<\/span> <\/span>jednom<\/span> <\/span>trenutku<\/span> <\/span>razvija<\/span> <\/span>senzomotorni<\/span> <\/span>de<\/span>fi<\/span>cit<\/span> <\/span>koji<\/span> <\/span>je<\/span> <\/span>obi\u010dno<\/span> <\/span>progresivan.<\/span> <\/span>Naj\u010de\u0161\u0107i<\/span> <\/span>razlog<\/span> <\/span>je<\/span> <\/span>razvoj<\/span> <\/span>tromboze<\/span> <\/span>rekonstruisanog<\/span> <\/span>arterijskog<\/span> <\/span>segmenta<\/span> <\/span>(intimalni<\/span> <\/span>fl<\/i><\/span>ap<\/i><\/span>,<\/span> <\/span>kinking,<\/i><\/span> <\/i><\/span>prizidni<\/span> <\/span>tromb,<\/span> <\/span>iregularna<\/span> <\/span>suturna<\/span> <\/span>linija,<\/span> <\/span>disekcija<\/span> <\/span>itd.).<\/span> <\/span>Tehni\u010dka<\/span> <\/span>gre\u0161ka<\/span> <\/span>je<\/span> <\/span>preventabilna.<\/span> <\/span>A<\/span> <\/span>mo\u017ee<\/span> <\/span>se<\/span> <\/span>korigovati,<\/span> <\/span>ali<\/span> <\/span>unutar<\/span> <\/span>vremenskog<\/span> <\/span>limita<\/span> <\/span>(1<\/span>h<\/span><\/sup>).<\/span><\/p>\n

    U<\/span> <\/span>ovih<\/span> <\/span>pacijenata<\/span> <\/span>se<\/span> <\/span>re\u0111e<\/span> <\/span>nalaze<\/span> <\/span>drugi<\/span> <\/span>uzroci<\/span> <\/span>peroperativnog<\/span> <\/span>\u0161loga<\/span> <\/span>(reperfuziona<\/span> <\/span>lezija<\/span> <\/span>mozga,<\/span> <\/span>ekstenzivne<\/span> <\/span>lezije<\/span> <\/span>druge<\/span> <\/span>karotidne<\/span> <\/span>i\/ili<\/span> <\/span>vertebralne<\/span> <\/span>arterije,<\/span> <\/span>hipotenzija,<\/span> <\/span>intrakranijalna<\/span> <\/span>hemoragija).<\/span><\/p>\n<\/div>\n

    \"\"<\/p>\n

    \n

    Prizidna tromboza na ranom postoperativnom Duplex- ultrazvu\u010dnom nalazu.<\/em><\/p>\n<\/div>\n

    \"\"<\/p>\n

    \n

    Tromboza<\/span> <\/span>je<\/span> <\/span>u<\/span> <\/span>naj\u010de\u0161\u0107i<\/span> <\/span>uzrok<\/span> <\/span>perioperativnog<\/span> <\/span>\u0161loga.<\/span> <\/span>Zato<\/span> <\/span>mnogi<\/span> <\/span>predla\u017eu<\/span> <\/span>hitnu<\/span> <\/span>reoperaciju<\/span> <\/span>kod<\/span> <\/span>svakog<\/span> <\/span>perioperativnog<\/span> <\/span>\u0161loga.<\/span> <\/span>Naime<\/span> <\/span>dobitak<\/span> <\/span>od<\/span> <\/span>brze<\/span> <\/span>i<\/span> <\/span>uspe\u0161ne<\/span> <\/span>reoperacije<\/span> <\/span>je<\/span> <\/span>ve\u0107i<\/span> <\/span>od<\/span> <\/span>potencijalnog<\/span> <\/span>gubitka<\/span> <\/span>zbog<\/span> <\/span>nepotrebne<\/span> <\/span>reoperacije.<\/span> <\/span>Osim<\/span> <\/span>toga,<\/span> <\/span>urgentna<\/span> <\/span>dijagnostika<\/span> <\/span>(CT,<\/span> <\/span>MRI,<\/span> <\/span>pa<\/span> <\/span>i<\/span> <\/span>arteriogra<\/span>fi<\/span>ja)<\/span> <\/span>u<\/span> <\/span>slu\u010daju<\/span> <\/span>tromboze<\/span> <\/span>ka-<\/span> <\/span>rotidne<\/span> <\/span>arterije<\/span> <\/span>samo<\/span> <\/span>nepotrebno<\/span> <\/span>odla\u017ee<\/span> <\/span>jedinu<\/span> <\/span>terapiju,<\/span> <\/span>a<\/span> <\/span>to<\/span> <\/span>je<\/span> <\/span>revaskularizacija.<\/span><\/p>\n

    U<\/span> <\/span>slu\u010daju<\/span> <\/span>tromboze<\/span> <\/span>karotidne<\/span> <\/span>arterije<\/span> <\/span>vreme<\/span> <\/span>je<\/span> <\/span>kriti\u010dan<\/span> <\/span>faktor.<\/span> <\/span>Ako<\/span> <\/span>se<\/span> <\/span>revas-<\/span> <\/span>kularizacija<\/span> <\/span>ne<\/span> <\/span>desi<\/span> <\/span>u<\/span> <\/span>prvih<\/span> <\/span>sat<\/span> <\/span>vremena<\/span> <\/span>reverzibilno<\/span> <\/span>ishemi\u010dno<\/span> <\/span>tkivo<\/span> <\/span>\u0107e<\/span> <\/span>se<\/span> <\/span>konvertirati<\/span> <\/span>u<\/span> <\/span>hemoragi\u010dni<\/span> <\/span>infarkt<\/span> <\/span>mozga.<\/span><\/p>\n

    Pacijenti<\/span> <\/span>sa<\/span> <\/span>te\u0161kim<\/span> <\/span>(<\/span>major<\/b><\/span>)<\/span> <\/span>neurolo\u0161kim<\/span> <\/span>de<\/span>fi<\/span>citom<\/span> <\/span>se<\/span> <\/span>urgentno<\/span> <\/span>reoperi\u0161u<\/span> <\/span>osim<\/span> <\/span>ako<\/span> <\/span>nisu<\/span> <\/span>u<\/span> <\/span>komi,<\/span> <\/span>ili<\/span> <\/span>ako<\/span> <\/span>je<\/span> <\/span>bilo<\/span> <\/span>dovoljno<\/span> <\/span>vremena<\/span> <\/span>da<\/span> <\/span>se<\/span> <\/span>kontrolnom<\/span> <\/span>Duplex-<\/span> <\/span>sonogra<\/span>fi<\/span>jom<\/span> <\/span>i\/ili<\/span> <\/span>arteriogra<\/span>fi<\/span>jom<\/span> <\/span>isklju\u010di<\/span> <\/span>tehni\u010dka<\/span> <\/span>gre\u0161ka<\/span> <\/span>i\/ili<\/span> <\/span>tromboza<\/span> <\/span>operisane<\/span> <\/span>arterije.<\/span><\/p>\n

    Pacijenti<\/span> <\/span>sa<\/span> <\/span>blagim<\/span> <\/span>(<\/span>minor<\/b><\/span>)<\/span> <\/span>neurolo\u0161kim<\/span> <\/span>de<\/span>fi<\/span>citom<\/span> <\/span>se<\/span> <\/span>reoperi\u0161u<\/span> <\/span>kada<\/span> <\/span>je<\/span> <\/span>tokom<\/span> <\/span>primo-operacije<\/span> <\/span>bilo<\/span> <\/span>nagove\u0161taja<\/span> <\/span>tehni\u010dkih<\/span> <\/span>problema,<\/span> <\/span>ili<\/span> <\/span>ako<\/span> <\/span>kontrolna<\/span> <\/span>Duplex-<\/span> <\/span>sonogra<\/span>fi<\/span>ja<\/span> <\/span>ili<\/span> <\/span>arteriogra<\/span>fi<\/span>ja<\/span> <\/span>uka\u017eu<\/span> <\/span>na<\/span> <\/span>prisustvo<\/span> <\/span>tehni\u010dke<\/span> <\/span>gre\u0161ke<\/span> <\/span>sa<\/span> <\/span>trombozom<\/span> <\/span>arterije.<\/span><\/p>\n

    Reoperacija;<\/b> <\/b>Urgentno, nakon otkrivanja fiksiranog postoperativnog neurolo\u0161kog deficita (sa ili bez kontrolnog Duplex-sonografskog ispitivanja ar- teriografije i CT-a) pacijenta treba transportovati u operacionu salu. Neophodno je da revaskularizacija bude izvedena u okviru 1h od po\u010detka simptoma.<\/p>\n

    Prioritet tokom reoperacije je urgentno uspostavljanje cerebralne perfuzije. Smisao reoperacije je urgentna trombektomija i definitivno otklanjanje hemodinamskog uzroka koji bi mogao da dovede do ponovne endarterektomisanog segmenta.Ako se hemodinamski problem nalazi distalno od primarne rekonstrukcije obi\u010dno je neophodno produ\u017eenje by<\/i> <\/i>pass<\/i> <\/i>grafta.<\/p>\n

    Neophodna je brza trombektomija sa plasiranjem privremenog intraluminalnog<\/i> <\/i>shunt<\/i>-a.Obi\u010dno se koristi op\u0161ta endotrahealna anestezija. Otklanjanje tromba, koji se naj\u010de\u0161\u0107e nalazi u nivou karotidne bifurkacije, je dovoljno za uspostavljanje retrogradnog toka iz unutra\u0161nje karotidne arterije. Ako je do\u0161lo do propagacije tromba distalno do karotidnog sifona mo\u017ee biti neophodna trombektomija Fogarty<\/i> <\/i>kateterom. Kateter se ne sme forsirano plasirati ako se nai\u0111e na rezistenciju. Najmanja neopreznost prilikom guranja Fogarty<\/i> <\/i>katetera mo\u017ee da uzrokuje leziju arterije i stvaranje karotido-kavernozne fistule. Kad se otkloni tromb treba definitivno otkloniti tehni\u010dki problem (intimalni flap, kinking, neravnine na suturnoj liniji).<\/p>\n

    Ako se pri reeksploraciji rekonstruisane arterije ne na\u0111e njena okluzija trombom ili tehni\u010dki defekt treba na\u010diniti intraoperativnu kontrolnu arteriografiju. Ako ona vizuelizira tehni\u010dku gre\u0161ku treba je korigovati.<\/p>\n

    Posle reoperacije treba nastaviti intenzivan kardiolo\u0161ki i neurolo\u0161ki monitoring. Rehabilitacija i fizikalna terapija treba da po\u010dne \u0161to ranije (sutradan). Pacijent slede\u0107eg dana treba da se hrani peroralno ako je za to sposoban, ili kroz na- zogasti\u010dnu sondu ako nije uspostavljen akt gutanja. Iskusni neurolog treba da vodi dalju medikamentoznu terapiju: antiedematozno le\u010denje, antikoagulantna terapija, rehidratacija i korekcija elektrolitnog balansa, antibiotik itd. Ako reoperacija nije na\u0161la tehni\u010dku gre\u0161ku i\/ili trombozu operisane arterije treba ispitati etiologiju peroperativnog \u0161loga (kontrolna Duplex-sonografija, MSCT arteriografija, transkranijalni Doppler, transezofagealna ehokardiografija, CT i\/ili MRI mozga).<\/p>\n

    Ponovljene operacije (redo) optere\u0107ene su znatno ve\u0107om u\u010destalo\u0161\u0107u komplikacija, zato prva operacija odre\u0111uje dalju sudbnu pacijenta.<\/p>\n

    \n<\/div>\n


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

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