Valor prognóstico da creatinofosfoquinase no pós-operatório de clipagem de aneurisma cerebral

• Ano de defesa: 2016
• Autor(a) principal: Cetl, Atsuko Nakagami [UNIFESP]
• Tipo de documento: Dissertação
• Tipo de acesso: Acesso aberto
• Idioma: por
• Instituição de defesa: Universidade Federal de São Paulo (UNIFESP)
• Palavras-chave em Português: Intracranial aneurysm; Subarachnoid hemorrhage; Creatinekinase; Clinical evolution; Aneurisma intracraniano; Hemorragia subaracnóidea; Creatinoquinase; Evolução clínica
• Link de acesso: https://sucupira.capes.gov.br/sucupira/public/consultas/coleta/trabalhoConclusao/viewTrabalhoConclusao.jsf?popup=true&id_trabalho=4241796; http://repositorio.unifesp.br/handle/11600/47096

Introduction: Subarachnoid hemorrhage (SAH) due to cerebral aneurysm has always been a concern in clinical practice for its high morbidity and mortality. Although there is a vast literature on the bad or good prognostic factors, none of them alone has shown to be effective. The creatine phosphokinase (CPK ) and CKBB fraction ( found in brain tissue ) have been reported in the literature as indicators of brain injury . Objective: To compare the values of CPK in the immediate postoperative period (IPO) between HSA (bleeding prior to surgery) and incidental (bleeding was not presented) groups; and to observe its prognostic value in this sample. Casuistry and Methods: This was an observational and retrospective study, analyzing the medical records of patients from the neuroanesthetic movement of the Surgical Center of the Hospital São Paulo - Paulista Medical School - EPM that undergone craniotomy for brain aneurysm clamping within the period 2008-2012, with postoperative care in the Neuro-Intensive Care Unit and in the Nursing Unit of Neurosurgery. Inclusion criteria were patients who had CPK dosage in the IPO and / or the first postoperative day and undergone clipping of cerebral aneurysm. The exclusion criteria were: patients who did not have CPK and / or CKMB collected postoperatively; brain aneurysm surgery performed with total circulatory arrest technique; when the electronic and / or printed records were not found. 195 adult patients were found (30 to 70 years old), 45 were excluded. Thus, the final sample consisted of 150 patients, in which demographic, clinical, laboratory and surgical data were collected. Results: Out of 150 patients, 99 had HSA and 51 incidental aneurysm. The average age was in the sixth decade for both groups, with female predominance in both groups (69 women in the HSA group and 47 women in the incidental group), but significantly more males in the group of HSA than in the incidental group; there was no significant difference in the frequency of ethnic groups white and African descent patients when comparing the two groups. Regarding the clinical aspect, most of the patients had hypertension (73.2% of patients in the HSA group and 67.7% of patients in the incidental group), and history of smoking (57.7% of patients in group HSA and 54.8% of patients in the incidental group) and in greater proportion than general population. In relation to the Hunt and Hess scale, a greater number of patients had grade 1 and 2, and for the Fisher scale, the female group had the worst grade (3-4). The vasospasm was more frequent in the HSA group, but there was not difference with other clinical complications, such as infection, fluid and electrolyte disturbance, re-operation, re-intubation, ARI (acute renal failure), stroke and death. There was a significant increase of number of days in the ICU (intensive care unit) and number of days of mechanical ventilation (MV) in the HSA versus the incidental group. For the surgical aspects, the anterior circulation aneurysms were more frequent; there was no difference between groups in relation to the surgical time and the frequency of temporary clipping, but there was a higher number of aneurysm intraoperative rupture in the HSA group. For the laboratory aspects, CPK values of IPO (immediate postoperative period) were significantly higher in the HSA group (median, 366 UI / L with percentiles 25% -75% of 235-544) than in the incidental aneurysm group (median 291 UI / percentiles of 25% -75% from 235 to 372.5 IU / L); there was no significant difference between CPK levels when comparing the groups with and without vasospasm, with and without re-operations, with and without intraoperative rupture, with and without temporary clipping. There was no correlation of CPK values with age, duration of surgery and mechanical ventilation. The intra-group analysis of patients with HSA was performed due to the difference of CPK values of POI between the male and female subgroups: there was no difference in ethnicity between these subgroups; there was no difference in the number of patients when analyzing the hidro-electrolytic disorders, re-intubation, infection, days of mechanical ventilation or length of stay in the ICU. However, there was significant difference when the duration of surgery was compared, with positive correlation between CPK levels of the POI and surgery time (but low correlation). Futhermore, there was a significant increase in the values of CPK in patients with hidro-electrolytic changes, and there was low correlation between the values of CPK in the HSA group and blood glucose values. Conclusions: In the immediate postoperative period (IPO) of cerebral aneurysm clipping, the values of CPK were significantly higher in the HSA group (bleeding prior to surgery); there was an increase of the absolute values of CPK in the immediate postoperative period of brain aneurysm clipping in relation to the normal values, with further increase in the first postoperative ; the increase of CPK was higher in men with HSA, in the presence of hydro-electrolytic alterations and with longer duration of surgery; there was no correlation between CPK and the patient's prognosis considering the variables analyzed in this study.