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2017, vol. 74, br. 12, str. 1183-1188
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Da li treba čekati spontani oporavak slabosti trećeg kranijalnog nerva nastale nakon koilinga PComA aneurizme ili sprovesti operativno lečenje?
To wait for a spontaneous recovery of the third cranial nerve palsy occurring after the coiling of a PComA aneurysm or to implement surgical treatment?: A case report
aKlinički centar Kragujevac, Centar za neurohirurgiju, Srbija + Univerzitet u Kragujevcu, Fakultet medicinskih nauka, Srbija bUniverzitet u Kragujevcu, Fakultet medicinskih nauka, Srbija + Univerzitet u Kragujevcu, Fakultet medicinskih nauka, Srbija cKlinički centar Srbije, Klinika za neurohirurgiju, Beograd, Srbija + Univerzitet u Beogradu, Medicinski fakultet, Srbija
e-adresa: vojinkg@gmail.com
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.
Abstract
Introduction. In the last two decades a method of endovascular embolization has been imposed as a method of choice in the treatment of unruptured intracranial aneurysms. Therefore, the problem of treating posterior communicating artery (PComA) aneurysms presenting with the third cranial nerve (TCN) palsy has become even more complex. The case of a patient reported in the paper itself has presented a dilemma of whether to wait for spontaneous resolution of ophthalmoplegia developed after the coiling of a PComA aneurysm or whether to implement an early surgical treatment. Case report. An unruptured saccular aneurysm, directed inferolaterally in the right internal carotid artery (ICA) segment in the position of the PcomA origin, was diagnosed in a 58-year-old male patient. The aneurysm was measuring 9 mm in diameter while the neck was measuring 5 mm. The day before the planned embolization, the patient developed ipsilateral ophthalmoparesis, whereas the first day after the endovascular procedure was completed, the patient developed right-sided complete ophthalmoplegia. Ten weeks after the endovascular embolization our team decided to perform a microsurgical treatment including aneurysm clipping and coil extraction. Eighteen months after the surgery, the patient made a full recovery of the functions of musculus (m) levator palpabrae, m. rectus medialis and pupillary function, with a partial recovery of the functions of m. obliqus inferior, m. rectus inferior and m. rectus superior. Conclusion. According to medical research and literature, the partial recovery of the TCN palsy is expected to happen in the first few weeks after embolization. Despite the completion of endovascular treatment progression of ophthalmoparesis to ophthalmoplegia without any symptoms of clinical improvement after 10 weeks is considered to be an indicator of longstanding TCN compression, which can lead to irreversible nerve damage. Despite the increase in the use of an endovascular embolization method in the treatment of PComA aneurysms preceeded by the TCN palsy, neurosurgical treatment is believed to have been necessary. Still, there is one question left to be answered - did we react too late in this particular case.
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