Da li treba čekati spontani oporavak slabosti trećeg kranijalnog nerva nastale nakon koilinga PComA aneurizme ili sprovesti operativno lečenje?

  • Miodrag Peulić Clinical Center Kragujevac, Center for Neurosurgery, Kragujevac, Serbia; University of Kragujevac, Faculty of Medical Sciences, Department of Surgery, Kragujevac, Serbia
  • Vojin Stevo Kovačević Clinical Center Kragujevac, Center for Neurosurgery, Kragujevac, Serbia; University of Kragujevac, Faculty of Medical Sciences, Department of Surgery, Kragujevac, Serbia
  • Marina Miletić Kovačević University of Kragujevac, Faculty of Medical Sciences, Department of Surgery, Kragujevac, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
  • Danica Grujičić Clinical Center of Serbia, Clinic for Neurosurgery, Belgrade, Serbia; University of Belgrade, Faculty of Medicine, Belgrade, Serbia
DOI: https://doi.org/10.2298/VSP160317235P
Ključne reči: intracranial aneursym||, ||aneurizma, intrakranijalna, oculomotor nerve||, ||n. oculomotorius, , embolization, therapeutic||, ||embolizacija, terapijska, neurosurgical procedures||, ||neurohirurške procedure, ophthalmoplegia||, ||oftalmoplegija, recovery of function||, ||funkcija, povratak

Sažetak


Uvod. U poslednje dve decenije metoda endovaskularne embolizacije nametnula se kao metoda izbora u lečenju nerupturiranih intrakranijalnih aneurizmi. Stoga je problem lečenja aneurizmi u regiji zadnje komunikativne arterije (PComA), udružene sa slabošću trećeg kranijalnog nerva (TKN), postao još kompleksniji. Slučaj bolesnika prikazanog u ovom radu stvorio je dilemu da li treba čekati spontani oporavak oftalmoplegije koja je nastala nakon embolizacije aneurizme na PComA ili je potrebno sprovesti rano operativno lečenje? Prikaz bolesnika. Kod bolesnika muškog pola životne dobi od 58 godina dijagnostikovana je nerupturirana inferolateralno orijentisana bilobarna aneurizma na desnoj unutrašnjoj karotidnoj arteriji – arteria carotis interna (ACI) u regiji ishodišta PComA, dijametra 9 mm i širine vrata 6 mm. Dan pre planirane embolizacije kod bolesnika se javila ipsilateralna oftalmopareza, a prvog dana nakon endovaskularne procedure došlo je do razvoja kompletne desnostrane oftalmoplegije. Nakon 10 nedelja perzistentne oftalmoplegije doneli smo odluku da se sprovede operativno lečenje u vidu klipsovanja aneurizme i ekstrakcije koilova. Nakon 18 meseci od operacije došlo je do potpunog oporavka funkcije musculus (m.) levator palpabrae, m. rectus medialis i pupilarne funkcije, sa parcijalnim oporavkom funkcije m.obliqus inferior, m. rectus inferior i m.rectus superior. Zaključak. Prema literaturi, očekivano vreme, barem delimičnog oporavka TKN nakon embolizacije je tokom prvih nekoliko nedelja. Progresija oftalmopareze u ofalmoplegiju uprkos sprovedenom endovaskularnom lečenju, a bez kliničkog poboljšanja nakon 10 nedelja od sprovođenja istog, shvaćena je kao indikator izražene kompresije TKN koja bi mogla dovesti do ireverezibilnog oštećenja nerva. Uprkos sve većoj učestalosti metode endovaskularne embolizacije u lečenju aneurizmi u regiji PComA koje su praćene preoperativnom slabošću TKN, smatramo da je operativno lečenje bilo neophodno. Ostaje pitanje da li je naša reakcija u ovom slučaju zakasnila?

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Objavljeno
2018/08/23
Broj časopisa
Vol. 74 Br. 12 (2017)
Rubrika
Prikaz bolesnika