Hemorragia subaracnoidea aneurismática
Epidemiología
La hemorragia subaracnoidea por aneurisma intracraneal (HSA aneurismática),representa el 5% de todo accidente cerebrovascular, con una edad media de 55 años 1),2), lo que confiere a un riesgo de por vida de alrededor de medio por ciento.
Afecta a 30.000 personas al año en los Estados Unidos (Bederson y col., 2011; Roger y col., 2011).
En Finlandia por motivos desconocidos, se han reportado cifras que triplican esta incidencia.
La edad de presentación más frecuente en la HSA es alrededor de los 55 años, aumentando la incidencia al aumentar la edad. En los estudios epidemiológicos analizados, se aprecia una mayor incidencia (entre 1.6 y 4.5 veces) en mujeres (Roda y col., 2000).
En un estudio efectuado en Noruega se aprecia un ligero aumento en la incidencia con el tiempo, lo cual puede explicarse por diferencias en los procedimientos de diagnóstico aunque la mortalidad se mantuvo estable durante los 23 años de seguimiento (Sandvei y col., 2011).
Se puede presentar asociado a un hematoma subdural con una incidencia del 1,8 %, de los cuales un 34 % tuvieron un resultado favorable.3).
Factores de riesgo
El tabaquismo y la hipertensión aumentan el riesgo de hemorragia subaracnoidea aneurismática dos a tres veces, mientras que una predisposición familiar aumenta el riesgo seis veces (Rasing y col., 2012).
Vlak y col., describen además de estos factores, la hipercolesterolemia.
La incidencia y el riesgo varía ampliamente de acuerdo con los perfiles de factores de riesgo.
Deberían evaluarse en estudios de coste-efectividad, si las personas con alto riesgo presentarían un beneficio del cribado (Vlak y col., 2013).
Fisiopatología
El reclutamiento de leucocitos y la respuesta inflamatoria, juegan un papel importante en la fisiopatología.
Existe un aumento de factor nuclear kappa B (NF-kB), así como los niveles de TNF-α, IL-1β y IL-6.
Diagnóstico
Tras un TAC se debería completar mediante angio-TAC la posible existencia de un aneurisma cerebral.
Puede mostrar 3 patrones de recidiva hemorrágica: un patrón de sangrado activo, rápido, con extravasación de contraste , un seguno patrón que permite mostrar, sangrado activo con fuga de contraste en la fase venosa tardía y un tercer patrón de aumento del hematoma. El factor de riesgo y signo de mal pronóstico es el de un diámetro del aneurisma (≧ 7 mm) y extravasación de contraste durante la angio-TAC.
Después se debería de completar el estudio con una panangiografía convencional.
De 352 pacientes que ingresaron con HSA espontánea desde 2003 hasta 2008, 68 (19,3%) tenían una angiografía inicial negativa. La edad media fue 59,5 ± 14, y 33 eran mujeres. En la TC, 27 (39,7%) pacientes presentaron un ptrón de hemorragia perimesencefálica. 33 (48,5%) una hemorragia subaracnoidea difusa, 6 (8,8%) HSA cortical, y 2 (2,9%) xantocromía solamente. Sesenta y un pacientes tenían grados (I-III) de Hunt y Hess , y siete tenían (IV-V). Otros estudios de diagnóstico incluyeron la repetición de la angiografía (54), RM cerebral y espinal (20), y repetir de la angio-TAC (15). Una causa estructural de la hemorragia se determinó en seis (8,8%) pacientes, de los cuales 4 tenían HSA difusa y 2 HSA cortical. Entre ellos, se detectaron dos aneurismas (2,9%) que se cliparon. Veintinueve pacientes (42,6%) experimentaron complicaciones médicas, con infección (18), problemas cardiovasculares (12), y vasoespasmo (10). Las cirugías adicionales incluyeron 13 derivaciones ventrículares, 4, traqueostomías y 9 colocaciones de tubos gástricos. Resultado favorable (MRS = 0-2) se registró en 49 (72,1%) pacientes y desfavorable (3-6) en 19 (17,49%), con un (1,2%) de mortalidad hospitalaria. La edad y el patrón de sangrado difuso fueron predictores significativos de resultado desfavorable. La incidencia global de aneurismas en pacientes con angiografía negativa es baja (2,9%) (Lin y col., 2012).
Complicaciones
Resangrado: Es una complicación frecuente, sobre todo en las primeras horas tras la hemorragia inicial, y ocurre en un 10% a 22% de los pacientes que acuden al hospital 4),5), 6), 7), 8), 9).
Pronóstico
Ha mejorado poco a poco desde mediados de la década de 1980. Esta mejora puede deberse a la intervención aneurisma temprana, el uso de nimodipina, y una mejora de la atención en cuidados críticos. A pesar de esta mejora, la mortalidad se mantiene en alrededor del 40%, y muchos sobrevivientes tienen un déficit neurológico permanente, cognitivo y déficits neuropsicológicos.
Los ensayos clínicos aleatorizados han probado terapias farmacológicas, pero pocas han tenido éxito. Hay muchas explicaciones para el fracaso de estos ensayos, que incluyen intervenciones ineficaces, inadecuados tamaños de la muestra, efectos secundarios del tratamiento, y medidas de resultado insensibles o inapropiadas.
El resultado a menudo se evalúa con una escala dicotómica que fue desarrollado para la lesión cerebral traumática hace 40 años, a tal fin se ha creado la Subarachnoid Hemorrhage International Trialists Data Repository 10)
La tasa de mortalidad es de aproximadamente 35%, el 25% de los sobrevivientes tienen un resultado favorable, y sólo un pequeño grupo se recuperan por completo 11)
La tasa de resangrado en la fase hiperaguda (en menos de 6 horas) es del 10,9% con mal pronóstico (Wu y col., 2012).
Del 85% de los pacientes que sobreviven, aproximadamente un tercio desarrollan una lesión cerebral (Roger y col., 2011), lo cual se debe a la isquemia cerebral tardía.
La mortalidad hospitalaria es del 26% (Lagares y col., 2011).
Pronóstico psicosocial
Las deficiencias cognitivas son comunes, y la evaluación clínica importante para su manejo. El Montreal Cognitive Assessment (MoCa) parece superior al Mini-Mental State Examination (MMSE) (Wong y col., 2013).
Una base de datos puede ser un instrumento ideal para mejorar el conocimiento sobre esta enfermedad en nuestro medio ambiente y lograr mejores resultados. Sería deseable que esta base de datos en el futuro podría ser el origen de un registro nacional (Lagares y col., 2008).
Afecta a la calidad de vida relacionada con la salud en gran medida, incluso 10 años después del inicio, lo que indica una necesidad de seguimiento y apoyo de los pacientes a largo plazo (Vogelsang y col., 2013).
Los familiares y amigos pueden ser excesivamente temerosos con el paciente, y estos temores podrían desempeñar un papel crítico en la mala recuperación mostrada por muchos pacientes 12)
Resultados
El grado de respuesta inflamatoria con liberación de citoquinas se asocia con pobres resultados, y en estos pacientes se ha podido comprobar niveles sistémicos altos de IL-6, los cuales han tenido un efecto beneficioso con antiinflamatorios no esteroideos 13).
Guías
En el 2011 el grupo de estudio de la patología cerebrovascular de la Sociedad Española de Neurocirugía propone una guía general, sin embargo, se pueden modificar, incluso de manera significativa de acuerdo a las circunstancias relativas de cada caso clínico y las variaciones en los procedimientos diagnósticos y terapéuticos disponibles en el centro de asistencia de cada paciente (Lagares y col., 2011).
Libros recomendados
Bibliografía
Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, et al. (2011) American Heart Association (2009) Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 40: 994–1025.
Lagares, A, P de Toledo, J A Fernández-Alén, J Ibáñez, F Arikan, R Sarabia, F Ballenilla, et al. 2008. [Spontaneous Subarachnoid Haemorrhage multicenter database from the Group for the Study of Vascular Pathology of the Spanish Society for Neurosurgery: presentation, inclusion criteria and development of an internet-based registry]. Neurocirugía (Asturias, Spain) 19, no. 5 (Octubre): 405-415.
Lagares, A, P A Gómez, J F Alén, F Arikan, R Sarabia, A Horcajadas, J Ibañez, et al. 2011. [Aneurysmal subarachnoid hemorrhage: group of study of Cerebrovascular Pathology of the Spanish Society of Neurosurgery management guideline.]. Neurocirugia (Asturias, Spain) 22, no. 2 (Mayo): 93-115.
Lin, Ning, Georgios Zenonos, Albert H Kim, Stephen V Nalbach, Rose Du, Kai U Frerichs, Robert M Friedlander, and William B Gormley. 2012. “Angiogram-Negative Subarachnoid Hemorrhage: Relationship Between Bleeding Pattern and Clinical Outcome.” Neurocritical Care (February 16). doi:10.1007/s12028-012-9680-6. http://www.ncbi.nlm.nih.gov/pubmed/22350856.
Rasing, Ingeborg, Dennis J Nieuwkamp, Ale Algra, and Gabriel J E Rinkel. 2012. “Additional Risk of Hypertension and Smoking for Aneurysms in People with a Family History of Subarachnoid Haemorrhage.” Journal of Neurology, Neurosurgery, and Psychiatry (March 15). doi:10.1136/jnnp-2011-301147. http://www.ncbi.nlm.nih.gov/pubmed/22423116.
Roda J.M. ; Conesa G. ; Diez Lobato R. ; Garcia Allut A.; Gomez Lopez P. A. ; Gonzalez Darder J.M. ; Lagares A.; Ley Garcia A.; Lloret J.;Martinez Rumbo R.; Prada J. J.; de la Riva A.; Ruiz F.; Soto M. ; Campollo J. : Hemorragia subaracnoidea aneurismática. Introducción a algunos de los aspectos más importantes de esta enfermedad. Neurocirugía 2000; 11: 156-168
Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, et al. (2011) American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2011 update: a report from the American Heart Association. Circulation 123: e18–e209. FIND THIS ARTICLE ONLINE
Sandvei, M S, E B Mathiesen, L J Vatten, T B Müller, H Lindekleiv, T Ingebrigtsen, I Njølstad, et al. 2011. «Incidence and mortality of aneurysmal subarachnoid hemorrhage in two Norwegian cohorts, 1984-2007». Neurology (Noviembre 2). doi:10.1212/WNL.0b013e3182377de3. http://www.ncbi.nlm.nih.gov/pubmed/22049205.
Vlak, Monique H M, Gabriel J E Rinkel, Paut Greebe, Jacoba P Greving, and Ale Algra. 2013. “Lifetime Risks for Aneurysmal Subarachnoid Haemorrhage: Multivariable Risk Stratification.” Journal of Neurology, Neurosurgery, and Psychiatry (January 25). doi:10.1136/jnnp-2012-303783.
Vogelsang, Ann-Christin von, Kristina Burström, Yvonne Wengström, Mikael Svensson, and Christina Forsberg. 2013. “Health-Related Quality of Life 10 Years After Intracranial Aneurysm Rupture: A Retrospective Cohort Study Using EQ-5D.” Neurosurgery 72 (3) (March): 397–406. doi:10.1227/NEU.0b013e3182804686.
Wu, Te-Chang, Yu-Kun Tsui, Tai-Yuan Chen, Chien-Jen Lin, Tai-Ching Wu, and Wen-Sheng Tzeng. 2012. “Rebleeding of aneurysmal subarachnoid hemorrhage in computed tomography angiography: risk factor, rebleeding pattern, and outcome analysis.” Journal of Computer Assisted Tomography 36 (1) (January): 103-108. doi:10.1097/RCT.0b013e31823f2e57.
Bibliografía recomendada
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