Sneller is niet altijd beter: waarom injectiesnelheid bij embolisatie-ingrepen in de hersenbloedvaten van cruciaal belang is
Wie een hersenoperatie ondergaat, verwacht dat elk detail zorgvuldig gepland wordt. Toch hangt het succes van bepaalde behandelingen af van de ervaring en keuzes van de arts. Daarom groeit de interesse om cruciale factoren – zoals de keuze van katheterpositie of injectiesnelheden van bepaalde stoffen – beter te kwantificeren. Mijn thesis focust op cerebrale arterioveneuze malformaties (AVM’s): misvormde clusters van hersenbloedvaten waarbij slagaders en aders rechtstreeks verbonden zijn. Een mogelijke behandeling is endovasculaire embolisatie, waarbij de arts via een microkatheter een stollingsmiddel inspuit, bijvoorbeeld een middel genaamd Onyx, dat stolt in de bloedvaten en de AVM (deels) blokkeert. Ik onderzocht specifiek de invloed van de Onyx-injectiesnelheid, met behulp van computationele vloeistofdynamica (CFD): computermodellen die bloed- en Onyxstromingen virtueel nabootsen in een virtuele kopie van de patiënts bloedvatenstelsel, als het ware een digitale tweeling. Daarmee kan men veilig virtueel simuleren hoe het middel zich in de bloedvaten verspreidt en welke invloed verschillende behandelingsscenario’s hebben. De resultaten tonen aan dat de injectiesnelheid een cruciale parameter is die verder kwantitatief onderzocht dient te worden.
Een gevaarlijke wirwar van bloedvaten – en hoe artsen dit behandelen
Onze hersenen worden voorzien van zuurstof en voedingsstoffen door een uitgebreid netwerk van slagaders en aders, gelinkt door haarvaten, dat de bloedstroom reguleert. Bij een cerebrale arterioveneuze malformatie (AVM) gaat dit echter mis: dit is een vaatafwijking, gekenmerkt door een directe verbinding tussen slagader(s) en ader(s), zonder de gebruikelijke haarvaten ertussen. Dit leidt tot een complex netwerk van vaten dat de normale bloedcirculatie verstoort. De risico’s? Hersenbloedingen, epilepsie, andere neurologische problemen, etc. Een mogelijke behandeling is endovasculaire embolisatie: via een dunne katheter in de bloedvaten dicht bij de AVM injecteert de arts een stollingsmiddel, bijvoorbeeld Onyx, in het afwijkende vaatnetwerk. Daar stolt dit middel en wordt de AVM (gedeeltelijk) afgesloten, waardoor de kans op complicaties voor de patiënt verkleint.
Meten is weten
Het resultaat van zo’n ingreep hangt echter af van de keuzes en ervaring van de arts. Denk bijvoorbeeld aan vragen zoals: hoe dichtbij de AVM wordt de katheter geplaatst? In welk bloedvat zit de katheter? Hoeveel stollingsmiddel wordt ingespoten? Hoe wordt dit ingespoten? Enzovoort… Daarom groeit de interesse in kwantificatie van deze parameters die mogelijk de uitkomst beïnvloeden. Hiervoor zijn tools zoals computationele vloeistofdynamica (CFD) bijzonder waardevol; dit zijn computermodellen die de bloed- en Onyx-stroming virtueel kunnen nabootsen in een digitale tweeling van de patiënt. Zo kan de verspreiding van Onyx in de bloedvaten worden gesimuleerd voor verschillende behandelingsscenario’s en kan de invloed van bepaalde parameters op een veilige, virtuele manier geëvalueerd worden.
Virtueel experimenteren met injectiesnelheid
Mijn thesis onderzocht hoe de Onyx-injectiesnelheid de Onyx-verspreiding in de bloedvaten beïnvloedt, via CFD-simulaties voor één specifieke patiënt. Momenteel wordt deze parameter in ziekenhuizen niet routinematig opgevolgd, ondanks richtlijnen van de Food and Drug Administration (FDA) die een snelheid van 0.16 ml/min aanbevelen en een strikte bovengrens van 0.30 ml/min – vanwege schadelijke effecten op de bloedvaten bij dierenstudies. Het patiënt-specifieke bloedvatenstelsel werd virtueel geconstrueerd op basis van medische beelden, en drie injectiesnelheden werden gesimuleerd: 0.08 ml/min, 0.16 ml/min (aanbevolen) en 0.32 ml/min. Zowel Onyx- als bloedstromingen werden gemodelleerd, gebruikmakend van literatuurgegevens en patiënt-specifieke informatie. Het voordeel van deze computermodellen? Je kan op een veilige, virtuele manier experimenteren met verschillende injectiesnelheden (of andere parameters) zonder risico’s voor de patiënt.
Wat lieten de simulaties zien?
De simulatieresultaten toonden dat injectiesnelheid inderdaad een merkbare invloed heeft op het gedrag van de Onyx. Hogere snelheden kunnen in theorie voordelig zijn: kortere ingreep, dus minder verdoving en stralingsblootstelling. Het is echter belangrijk om na te gaan of een snelle injectie geen ongewenste effecten veroorzaakt. Volgens de simulaties versnellen hogere injectiesnelheden niet alleen de Onyx-progressie, maar veranderen ze ook de verdeling ervan over bloedvatvertakkingen stroomafwaarts. Om dit te kwantificeren, werd de verdeling van geïnjecteerde Onyx-massa over drie hartcycli (2.4 s) bepaald over twee vertakkingen stroomafwaarts van de katheter. Bij de lage injectiesnelheid (0.08 ml/min) stroomde 74% van de Onyx naar tak 1 en 26% naar tak 2. Voor de FDA-aanbevolen snelheid (0.16 ml/min) verdeelde de Onyx zich bijna gelijk (51% versus 49%). Bij de hoge snelheid (0.32 ml/min) draaide dit patroon om, met 39% naar tak 1 en 61% naar tak 2. Aangezien de katheter meer gericht was naar tak 1, betekent dit dat hogere injectiesnelheden de kans op ongewenste afsluiting van gezonde vaten (non-target embolisatie) kunnen vergroten. Een verklaring hiervoor is de verhoogde stromingsweerstand in tak 1 bij een hogere injectiesnelheid, doordat er meer en sneller viskeuze Onyx wordt geïnjecteerd, waardoor de stroming bemoeilijkt wordt.
Daarnaast veroorzaakten hogere injectiesnelheden een lichte stijging van de lokale drukverschillen (over een zone van ongeveer 4 mm net na de injectiesite), met maximale waarden van 0.44 Pa zonder Onyx-injectie en 4.47 Pa, 5.95 Pa en 8.85 Pa bij respectievelijk 0.08, 0.16 en 0.32 ml/min. Ook dit kan gelinkt worden aan de verhoogde stromingsweerstand in tak 1 bij een hogere injectiesnelheid, met als gevolg verhoogde drukken. Hoewel deze waarden klein bleven, wijzen verhoogde drukverschillen (en de daarmee gepaard gaande verhoogde wandschuifspanningen) wel op mogelijke risico’s voor vaatbeschadiging of bloedingen.
Wat betekent dit voor de patiënt?
Deze studie illustreert dat de injectiesnelheid de uitkomst van de behandeling sterk kan beïnvloeden. Toch wordt deze vandaag nauwelijks gemonitord; dit kan dus beter... Bovendien tonen de gebruikte methoden potentieel voor de toekomst. Denk bijvoorbeeld aan de ontwikkeling van een pre-interventionele simulatie-tool: een virtuele testomgeving waarin verschillende behandelingsscenario’s getest worden op een virtuele kopie van het patiënt-specifieke bloedvatenstelsel, op basis waarvan men vooraf de veiligste en meest effectieve strategie voor de patiënt kan bepalen.
Conclusie
Dit onderzoek bewijst dat de Onyx-injectiesnelheid een cruciale parameter is die de Onyx-verspreiding en drukken in bloedvaten kan beïnvloeden, en zo ook de uitkomst van een endovasculaire embolisatie. Toekomstig onderzoek moet grotere patiëntengroepen, geoptimaliseerde simulatie-workflows, experimentele validatie en aandacht voor invloed van verschillende parameters omvatten. De studie onderstreept ook het potentieel van CFD-simulaties om op termijn dit soort ingrepen veiliger en efficiënter te maken door bij te dragen aan virtuele planning voorafgaand aan effectieve ingrepen.
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