Alteraciones cognitivas en pacientes operados de aneurismas cerebrales en el Hospital de Clínicas

RESUMEN Introducción: la hemorragia subaracnoidea por sí misma puede dar lugar a un daño cerebral, por esto, en pacientes sin complicaciones los trastornos cognitivos pueden estar presentes. Objetivos: analizar las alteraciones neuropsicológicos en los pacientes operados de aneurismas cerebrales y los factores que se asocian a su desarrollo. Metodología: estudio analítico, observacional, ambispectivo, 2013-2020, que incluyó pacientes operados de aneurismas cerebrales rotos en el Hospital de Clínicas. La evaluación cognitiva se realizó con el mini examen cognitivo de Lobo. Se consideró alterado cuando la puntuación fue menor a 27. Se analizaron 12 variables asociando las mismas con el tema de estudio. Los datos fueron analizados con Epiinfo 7.2. Resultados: La edad mayor a 60 años se asoció al déficit cognitivo de forma significativa, así como también la lateralidad a izquierda, el uso de clipado temporario durante la cirugía, la ruptura del aneurisma en el intraoperatorio, el vasoespasmo y la hidrocefalia. No se asoció significativamente con el desarrollo de un trastorno cognitivo; el sexo, el nivel de escolaridad, la cantidad de sangre cisternal, la localización del aneurisma, el Glasgow de ingreso ni la fase en la cual se realzó la cirugía. Discusión: en general los hallazgos coinciden con la literatura. Llamó la atención que la escala de Fisher en la muestra estudiada no demostró tener una asociación significativa con el trastorno cognitivo, sin embargo, hay datos en la literatura que sostienen que la cantidad de sangre cisternal al ingreso es un fuerte predictor del estado cognitivo del paciente al alta.

ABSTRACT Introduction: subarachnoid hemorrhage itself can lead to brain damage, so in uncomplicated patient's cognitive disorders may be present. Objective: To analyze the cognitive impairments in patients following clipping of ruptured aneurysms and the factors that are associated with their development. Methodology: analytical, observational, ambispective study, 2013-2020, including patients operated for ruptured aneurysms at the Hospital de Clínicas. The cognitive evaluation was performed with the Lobo mini cognitive exam. It was considered altered when the score was less than 27. Twelve variables were analyzed associating them with the study topic. The data was analyzed with Epiinfo 7.2. Results: Age over 60 years was significantly associated with cognitive deficit, as well as left laterality, the use of temporary clipping during surgery, intraoperative aneurysm rupture, vasospasm, and hydrocephalus. It was not significantly associated with the development of a cognitive disorder; sex, level of education, amount of cisternal blood, location of the aneurysm, admission Glasgow, and the timing in which the surgery was performed. Discussion: In general, the findings coincide with the literature. It was noteworthy that the Fisher scale in the studied sample did not show to have a significant association with cognitive disorder, however, there are data in the literature that maintain that the amount of cisternal blood on admission is a strong predictor of the patient's cognitive state at discharge.

Casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas - Paraguay, desde el 2011 al 2019 / Casuistry, management and results of brain aneurysms at the Hospital de Clínicas - Paraguay, from 2011 to 2019

Introducción: La Hemorragia Subaracnoidea es el sangrado en el espacio subaracnoideo. La causa espontánea en la mayoría de las veces se debe a ruptura de un aneurisma cerebral. Objetivo: Describir la casuística, manejo y resultados de los aneurismas cerebrales en el Hospital de Clínicas. Pacientes y método: Estudio observacional, descriptivo, transversal, incluyendo pacientes operados de aneurismas cerebrales, mayores de 17 años, en el Hospital de Clínicas del 2011 al 2019. Las variables descriptas fueron: edad, sexo, motivo de consulta, estudios radiológicos, escala de Glasgow y Hunt y Hess, localización, segmento, cantidad, fase, clipado temporario, vasoespasmo e hidrocefalia. Resultados: Se incluyó 249 pacientes; 45% masculino, 65% femenino, con edad promedio de 47,5 años. El motivo de consulta más frecuente fue cefalea. Al ingreso tuvieron predominantemente Hunt y Hess 2, y, Glasgow 15. El 43,2% eran Fisher 4. El Glasgow de egreso fue mayor o igual a 14 en 82,1%. Se diagnosticó el 51,7% con arteriografía; el 50,9% de los aneurismas en la carótida interna y, fueron múltiples en 10,84%. Se operaron en fase aguda 28,3%, 65% en fase tardía y, el 6,7% de los aneurismas fue de hallazgo casual. En 36,44% de los casos se realizó clipado temporario y, en el 70,4% se perforó la lámina terminalis. La mortalidad fue de 4,2%. Presentaron vasoespasmo radiológico en un 46% y, vasoespasmo clínico en 24,5 %. El 11% fue sometido a craniectomía descompresiva y, 5,5% desarrolló hidrocefalia dependiente de VDVP. Conclusión: El clipado de los aneurismas cerebrales es una técnica con buenos resultados y la única accesible en el sector público.

Introduction: Subarachnoid hemorrhage is bleeding in the subarachnoid space. The spontaneous is caused most of the time by rupture of a cerebral aneurysm. Objective: Describe the casuistry, management and results of cerebral aneurysms at the Hospital de Clínicas. Patients and methods: Observational, descriptive, cross-sectional study including patients operated for cerebral aneurysms, older than 17 years, at the Hospital de Clínicas from 2011 to 2019. The variables described were: age, sex, reason for consultation, radiological studies, Glasgow and Hunt and Hess scale, location, segment, quantity, phase, temporary clipping, vasospasm and hydrocephalus. Results: 249 patients were included; 45% male, 65% female, average age 47.5 years. The most frequent reason for consultation was headache. At admission they had predominantly Hunt and Hess 2, and Glasgow 15. 43.2% were Fisher 4. The Glasgow of discharge was greater than or equal to 14 in 82.1%. 51.7% were diagnosed with arteriography; 50.9% internal carotid aneurysms, multiple 10.84%. 28.3% were operated in acute phase, 65% late phase, 6.7% were a casually found. In 36.44% of cases a temporary clipping was performed and in 70.4% the lamina terminalis was perforated. Mortality was 4.2%, radiological vasospasm 46%, clinical vasospasm 24.5%, 11% underwent decompressive craniectomy and 5.5% developed VDVP-dependent hydrocephalus. Conclusion: The clipping of cerebral aneurysms is a technique with good results and the only one in the public sector.

Surgical Management of Ruptured Posterior Circulation Aneurysms ­ A Single Center Experience

Objective The treatment of ruptured aneurysms of the posterior circulation is a controversy in neurosurgery. The aim of this work is to describe the experience and results of the early surgical treatment of this pathology at Centro Hospitalar do Porto. Method We retrospectively analyzed the medical records of all patients aged over 18 who, in the period between 1999­2013, were admitted to our center with the diagnosis of ruptured saccular posterior circulation aneurysm. The patients were clinically staged at admission using the Hunt & Hess (H&H) scale. The modified Glasgow Outcome Scale (mGOS) was used to assess the outcome at discharge and after 6 months. Results Between 1999­2013, 59 patients underwent surgery for ruptured posterior circulation aneurysms. Eighty percent of the patients were female, and their average age was 58.7 years. Posterior-inferior cerebellar artery aneurysms accounted for 49.2% of surgeries, while basilar aneurysms accounted for 28.8%. Upon admission, 86.4% of patients were classified as H&H1­3, and 13.6% as H&H4­5. The outcomes at discharge and at 6 months were as follows: at discharge, mGOS1 in 5.1%, mGOS2­3 in 18.6%, and mGOS4­5 in 76.3%; at 6 months, mGOS1 in 10.2%, mGOS2­3 in 10.2%, and mGOS4­5 in 79.6%. There was a statistically significant correlation between basilar aneurysms and worse outcomes (p » 0.011). No correlation was found between the values of the H&H scale upon admission and outcome. Conclusions The functional outcome of our group of patients is mainly in line with what is described in other series from the literature. However, there is a trend toward lower mortality but higher morbidity rates.

Objetivo O tratamento dos aneurismas rotos da circulação posterior é uma controvérsia neurocirúrgica. Pretende-se com este trabalho relatar a experiência e os resultados do tratamento cirúrgico precoce desta patologia no Centro Hospitalar do Porto. Métodos Foram analisados retrospectivamente os processos clínicos dos pacientes com idade > 18 anos que, no período entre 1999­2013, foram admitidos no nosso centro com o diagnóstico de aneurisma sacular roto da circulação posterior. Utilizou-se a escala de Hunt & Hess (H&H) para aferir a gravidade clínica dos pacientes, e a Escala de Outcome de Glagow modificada (mGOS) para aferir o outcome dos pacientes à data da alta e aos 6 meses. Resultados Entre 1999­2013, foram operados 59 pacientes com aneurismas rotos da circulação posterior. Oitenta por centro dos pacientes eram do sexo feminino, com uma média de idade média de 58.7 anos. Aneurismas da artéria cerebelosa posteroinferior foram responsáveis por 49,2% das cirurgias, ao passo que os da artéria basilar, por 28,8%. À admissão, 86,4% dos pacientes eram H&H1­3, e 13,6%, H&H4­5. O outcome à data da alta e aos 6 meses foi o seguinte: à data de alta, mGOS1 em 5,1%, mGOS2­3 em 18,6%, e mGOS4­5 em 76,3%; aos 6 meses, mGOS1 em 10,2%, mGOS2­ 3 em 10,2%, e mGOS4­5 em 79,6%. Verificou-se uma correlação estatisticamente significativa entre aneurismas da basilar e um pior outcome (p » 0,011). Não se verificou qualquer correlação entre os valores da escala de H&H à admissão e o outcome. Conclusões O outcome funcional do nosso grupo de pacientes está em linha com o descrito noutras séries da literatura. Contudo, destaca-se uma tendência para uma mortalidade mais baixa, mas uma morbilidade mais alta no nosso grupo de pacientes.