6 TRATTAMENTO DEGLI ANEURISMI INTRACRANIC
14. COMPLICANZE E CONTROINDICAZIONI DEI TRATTAMENT
14.5 Complicanze trombotiche ed emboliche
Una trombosi del vaso portante può essere secodaria ad un danno endoteliale prodotto dal microcatetere o microguida o può originare in corrispondenza dell'interfaccia della matassa di spirali. Gli emboli tendono a formarsi più frequentemente a livello del catetere guida. I principali fattori di rischio per complicanze tromboemboliche sono: prolasso delle spirali, trombofilia e vasospasmo. La percentuale di complicanze tromboemboliche va dal 3% al 17,6%, il numero di pazienti con sintomi neurologici temporanei o permanenti può raggiungere l'8,5%. Le
complicanze tromboemboliche però non comportano necessariamente un danno neurologico: in uno studio di Qureshi et al. ci fu un 8,2% di eventi tromboembolici ma solo il 5,4% dei pazienti sviluppò danni neurologici.
Per ridurre il rischio di comlicanze tromboemboliche si utilizza una terapia anticoagulante perioperatoria mediante eparina (generalmente l'ACT viene portato a 250-300s), che viene mantenuta per 24-48h dopo l'intervento. Secondo uno studio di Qureshi et al. l'eparinizzazione post-operatoria riduce il rischio di eventi tromboembolici dal 9.3% al 5.9%.
Il trattamento delle complicanze tromboemboliche prevede per prima cosa l'assicurarsi che l'eparinizzazione sia adeguata: se l'ACT è <250s si somministrano boli di eparina fino ad
ottenere valori di 250-300s (o 2 volte i valori basali). Se nonostante ciò ai controlli angiografici, eseguiti a brevi intervalli, il trombo si propaga o persiste ed è emodinamicamente significativo si procede con la trombolisi farmacologica.
La trombolisi farmacologica può essere locale (tramite microcatetere) o sistemica (EV o IA, nel caso non sia già presente un microcatetere e il trombo non sia facilmente raggiungibile) ed
trombolisi e continuare per 24h con un'infusione di eparina a basse dosi. Se il trombo continua ad essere emodinamicamente significativo si passa alla trombolisi meccanica.
La trombolisi meccanica si effettua mediante tromboaspirazione, stentriever o angioplastica con palloncino.
14.6 Controindicazioni:
• Controindicazioni assolute: grave allergia al mezzo di contrasto, insufficienza renale, gravidanza.
• Controindicazioni relative: moderata allergia al mezzo di contrasto, ipersensibilità all'eparina, patologia renale, controindicazioni all'anestesia generale, patologie della coagulazione, infezioni attive con batteriemia, caratteristiche dell' accesso arterioso (es: elevato grado di tortuosità/stenosi), caratteristiche dell'aneurisma (es: rapporto
sacca/colletto, localizzazione).
Queste controindicazioni non si applicano ai trattamenti delle emergenze dove il mancato intervento comporta un rischio maggiore per la vita del paziente.
15. CONCLUSIONI
Al giorno d'oggi, alla luce degli studi condotti sull'efficacia e i rischi dei trattamenti chirurgico e endovascolare, gran parte degli aneurismi intracranici possono essere trattati per via
endovascolare.
Nel decidere quale trattamento endovascolare utilizzare non si deve però seguire il ragionamento "un tipo di trattamento per tutti gli aneurismi".
La scelta va fatta in base alle caratteristiche dell'aneurisma, dei device disponibili e del paziente. Le più recenti tecniche endovascolari ed in particolare gli stent flow diverter non soppiantano quindi le altre tecniche endovascolari, ma vi si affiancano per fornire un'ulteriore scelta terapeutica al neuroradiologo interventista.
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