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Vol. 21. Issue 5.
Pages 373-380 (January 2010)
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Vol. 21. Issue 5.
Pages 373-380 (January 2010)
Flujometría por difusión termal para la medida del flujo sanguíneo cerebral regional en la cirugía de los aneurismas cerebrales
Using thermal diffusion flowmetry in the assesment of regional cerebral blood flow in cerebral aneurysm microsurgery
Visits
2011
F. Verdú-López
Corresponding author
franciscoverdu@hotmail.es

Correspondencia: Servicio de Neurocirugía. Hospital Clínico Universitario. Avda. Blasco Ibáñez, 17. 46010-Valencia.
, J.M. González-Darder, P. González-López, L. Botella Macia
Servicio de Neurocirugía. Hospital Clínico Universitario de Valencia. Servicio Valenciano de Salud. Valencia
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Resumen
Introducción

La flujometría por difusión termal (FDT) es una técnica que permite, mediante la implantación de una microsonda en una región cerebral de interés, determinar el flujo sanguíneo cerebral regional (FSCr) y su monitorización cuantitativa (ml/100g/min), continua y en tiempo real. El objetivo de nuestro trabajo es mostrar los detalles técnicos y resultados preliminares de esta técnica de monitorización durante la cirugía y el postoperatorio del tratamiento microquirúrgico de los aneurismas cerebrales, donde tendría valor para detectar y cuantificar fenómenos isquémicos relacionados con el clipaje temporal arterial o malposición del clip definitivo.

Material clínico

Han sido monitorizados cinco pacientes (4 mujeres y 1 hombre; edad media de 50.8 años), dos de ellos con aneurismas de arteria cerebral media, otros dos con sendos aneurismas de arteria comunicante posterior y coroidea anterior y uno con aneurisma de carótida interna paraclinoideo. Los pacientes fueron intervenidos con técnica microquirúrgica y clipaje de los aneurismas a través de un abordaje pterional. Se utilizó monitorización neurofisiológica peroperatoria y flujometría con microdoppler. Inmediatamente antes de la craneotomía se procedió a la colocación de la microsonda de FDT a través de un minitrépano sobre la línea coronal, en territorio de la arteria cerebral anterior (2cm de línea media) o de la cerebral media (6cm de línea media) y en sustancia blanca, a unos 2.5cm de profundidad. Los pacientes fueron monitorizados durante la cirugía y el tiempo en que estuvieron en la Unidad de Reanimación. Se realizaron un total de 14 clipajes temporales (rango 2–4) con un tiempo medio de clipaje de 7.2min (rango 1.6–16) y 16 (rango 2–8) recolocaciones de los clips definitivos. En el aneurisma paraclinoideo se utilizó la técnica de aspiración retrógrada manteniendo cerrada la carótida interna 45min. Se describen casos ilustrativos con diferentes registros demostrativos.

Conclusiones

El uso de la FDT permite una valoración cuantitativa y en tiempo real del FSCr de las áreas cerebrales de interés monitorizadas durante el tratamiento microquirúrgico de los aneurismas cerebrales, lo que hace posible detectar fenómenos isquémicos y evitar que se produzcan déficits neurológicos. La detección precoz de la isquemia permitiría aplicar medidas terapéuticas más precozmente y con mayor eficacia.

Palabras clave:
Aneurisma
Flujo sanguíneo cerebral
Flujometría mediante difusión termal
Isquemia
Monitorización intraoperatoria
Oclusión temporal arterial
Abreviaturas:
ACA
ACI
ACM
ACom
AComP
ACorA
CTA
FDT
FSC
FSCr
PEM
PESS
Summary
Introduction

The thermal diffusion flowmetry (TDF) is a technique that allows the measurement of the regional cerebral blood flow (rCBF) through an implanted microprobe in a cerebral region of interest. The monitoring is continuous, real-time and quantitative (ml/100g/min). The purpose of our clinical work has been to show the technical details and preliminary results by using this monitoring technique during the microsurgical management of cerebral aneurysms and along the postoperative period. The aim of the monitoring of the rCBF is to identify and evaluate ischemic events related with the temporary artery clipping or malposition of the final clip.

Clinical materials

A total of five patients have been monitored (4 woman and one man with an average age of 50.8 years). Two patients harboured one aneurysm in the middle cerebral artery, other two patients had two aneurysms each one on the internal carotid artery in the exit of the posterior communicating and anterior choroidal artery and the fifth harboured a paraclinoid internal carotid artery aneurysm. All patients were operated on using standard microsurgical techniques through a pterional approach. Surgery was done under neurophysiological monitoring and direct microdoppler fluometry assesment. Just before craniotomy the TDF microprobe was inserted 2,5cm deep into the white matter through a small burr-hole placed on the coronal line and 2cm away the midline to measure in the anterior cereral artery vascular sector and 6cm away of the midline to measure in the middle cerebral artery territory. Patients were under continuous monitoring during surgery and along the postoperative period in the recovery unit. A total of 14 temporary artery clippings (between 2–4) with an average total clipping time of 7.2 minutes (ranging 1.6 to 16) and 16 definitive clip replacements (ranging 2 to 8) were done at surgery. Patient with paraclinoid aneurysm was operated on using the retrograde aspiration technique and the internal carotid artery was kept closed 45 mimutes. keeping Some illustrative cases and demonstrative records are presented.

Conclusions

The use of TDF allows a quantitative real-time measurement of the rCBF in the areas of interest monitored during the microsurgical management of the cerebral aneurysms which leads to detect ischemic events helpping to avoid ischemic sequelae. The detection of ischemic events in real time would make possible the use of therapeutic measures ealier and more efficienty.

Key words:
Aneurysm
Cerebral blood flow
Thermal diffusion flowmetry
Intraoperative monitoring
Ischemia
Temporary arterial occlusion

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