Procena efikasnosti rane rehabilitacije nakon aneurizmalnog subarahnoidalnog krvarenja kod bolesnika operisanih u akutnom terminu

Abstract

Uvod: Subarahnoidalno krvarenje (SAH) predstavlja iznenadan prodor krvi u subarahnoidalni prostor i jedna je od najdramatičnijih cerebralnih disfunkcija, a nastaje apoplektiformno, najčešće usled rupture aneurizmatskog proširenja arterijskog krvnog suda. Glavni simptom je glavobolja. Brojne su komplikacije i to neurološke (reruptura, vazospazam, hidrocefalus, epi napadi) i somatske komplikacije (plućni edem, srčane aritmije, poremećaj elektrolita, teških krvarenja iz gastrointestinalnog trakta, najčešće želuca) i dr. Nakon postavljanja dijagnoze, kauzalni vid lečenja je isključivanje aneurizme iz cirkulacije i to hirurškim ili endovaskularnim pristupom. Termin za hiruršku intervenciju može biti akutni, u prvih 72 h od rupture aneurizme. Istraživanja kada je potrebno i bezbedno započeti sa ranom rehabilitacijom i vertikalizacijom, praktično nema. Cilj ovog istraživanja je uspostavljanje što bezbednijeg rehabilitacionog programa sa vertikalizacijom za bolesnike koji su operisani od subarahnoidalnog aneurizmalnog krvarenja u akutnom terminu. Metod: Studija je bila tipa randomizovanog kliničkog ogleda. Ispitivanje se sprovodilo na Klinici za neurohirurgiju Kliničkog centra Srbije i to u periodu od 1. VI 2013. do 1. VI 2015. Studija je odobrena od Etičkog komiteta Medicinskog fakulteta u Beogradu. U studiju su bili uključeni bolesnici Klinike za neurohirurgiju Kliničkog centra Srbije kojima je postavljena klinička dijagoza SAH, a koji su operisani u akutnom terminu tj. u prva tri dana od rupture aneurizme tj. ataka, a koji su preoperativno pripadali I, II ili III gradusu, bez obzira na lokalizaciju aneurizme. Obuhvatala je šezdeset pet bolesnika koji su operisani nakon rupture aneurizme u akutnom terminu i to podeljeni u grupu I (N= 34) koji su ranu rehabilitaciju sa vertikalizacijom započeli 2-5 dana od krvarenaj i grupu II (N= 31) koji su ranu rehabilitaciju odmah započeli ali vertikalizovani oko 12- og dana od krvarenja. Kod svih bolesnika smo pratili: rane komplikacije, vazospazam, ishemiju kao i procenu motornog stanja bolesnika. Ispitivali smo depresiju (Zung skalom), anksioznost (Zung skalom), kognitivni status, Mini mental testom (MMSE test), vršili procenu funkcionalnosti skalom za procenu funkcionalne nezavisnosti (FIM), kvalitet života (WHOQOL-BREF) i to na otpustu, mesec i tri meseca nakon operacije...

Introduction: The term subarachnoid hemorrhage (SAH) refers to sudden extravasation of blood into the subarachnoid space. As one of the most dramatic cerebral dysfunctions, it occurs suddenly, in most cases as a result of a ruptured arterial aneurism. The most common symptom of SAH is severe headache, often called thunderclap headache. A subarachnoid hemorrhage can have many complications, both neurological (a re-rupture of the aneurysm, vasospasm, hydrocephalus and epileptic seizures) and somatic (pulmonary edema, arrhythmia, electrolyte disturbances, and severe bleeding in the digestive tract, usually the stomach). After a positive diagnosis of SAH, patients receive causal treatment, i.e. the aneurysm is excluded from the blood flow using either the surgical or endovascular approach. A surgical procedure may be performed in the acute phase, within the first 72 hours after the ruptured aneurysm. To date, virtually no studies have been carried out into when it is preferred and safe to initiate early rehabilitation and verticalization. The aim of this study was to develop a safe rehabilitation and verticalization protocol for patients who have undergone surgical repair of acute SAH. Methods: The study was a randomized, clinical experimental design. It was carried out in the Neurosurgery Clinic of the Clinical Center of Serbia between June 2013 and June 2015. The investigation was approved by the Ethics Committee of the School of Medicine, University of Belgrade. All subjects were patients in the Neurosurgery Clinic of the Clinical Center of Serbia who had been diagnosed with SAH and undergone surgery in the acute phase of this life-threatening condition (i.e. within the first 3 days after aneurysm rupture; clinical status before surgery classified as grade I, II or III regardless of aneurysm location). These sixty-five subjects were evaluated in two groups. Group 1 (n=34) started early rehabilitation and verticalization on Days 2-5 post-bleeding, whereas Group 2 (n=31) started early rehabilitation immediately post-surgery and verticalization was initiated approximately Day 12 post-bleeding. All patients were monitored for early complications, vasospasm and ischemia; their motor status was assessed as well. Depression and anxiety (using the Zung scales), cognitive status (using the Mini-Mental State Examination) functional status (using the Functional Independence Measure or the FIM instrument) as well as quality of life (using the WHOQOL BREF scale) were assessed at discharge and at 1 and 3 months post-surgery...