A method for predicting the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period

 

The invention relates to medicine, namely, neurology and neurosurgery, and can be used to determine the outcome of surgical treatment. Analyze the combination of prognostically relevant attributes. Calculate the discriminant function Y according to the following formula: Y=5,79+(-0,02)X1+0,74X2+(-0,59)(X3+(-0,69)X4+(-1,34)X5+0,06X6where X1- the severity of somatic pathology: 1 - missing or blurred expressed, 2 - severe, 3 - pronounced; X2- clinical-anatomical shape hemorrhage: 1 - intracranial hematoma to 50 ml, not accompanied by dislocation of the brain, 2 - intracranial hematoma of more than 50 ml, accompanied by dislocation of the brain and/or occlusion or tamponade liquor-conducting paths; X3intracranial hypertension: 1 - absent, 2 - blurred expressed, 3 - severe, 4 - pronounced; X4- hydrocephalus: 1 - absent, 2 - blurred expressed, 3 - pronounced; X5- the severity of the patient's condition on the day of surgery: 1 - offset, 2 - subcompensation-21 days 5 - more than 21 days. When the value of The0 predicts favorable outcome , and when I < 0 fatal. The method allows us to simplify the forecasting and to get a reliable result. 3 table.

The invention relates to medicine and can be used to determine the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period, based on the combination of prognostic features and their values in a particular patient.

Hemorrhagic stroke (hypertension, stroke, hypertensive intracerebral hemorrhage) is bleeding in the brain or under his shell, resulting from pathological changes of cerebral vessels in hypertension and atherosclerosis.

According to domestic and foreign literature, the frequency of hypertensive stroke reaches 24.4 percent per 100.000 population per year and 25-30% from other forms of violations of cerebral circulation. Mortality in hypertensive stroke reaches 40-50%, and disability - 75% among surviving patients, which leads to the significance of socio-economic problems of the environment are divided into primary and secondary. The primary intracerebral hemorrhage include hemorrhage due to arterial hypertension (average 70-90% of cases). Secondary intracerebral hemorrhage are due to coagulopathy (10-26% of observations), hemorrhage into the tumor (1-3,5%), arteriovenous malformations (7%), vasculopathy (5%). Up to 80% of cases of primary intracerebral hemorrhage localized supratentorial (in large hemispheres of the brain), 20% - subtentorial (in the cerebellum and brain stem).

Despite the development and implementation of new diagnostic methods and surgical techniques, the improvement of intensive care benefits, convincing advantages in the surgical treatment of hemorrhagic stroke compared with conservative yet. This is the reason for the rather low surgical activity in the treatment of this disease is the frequency of surgical interventions in primary intracerebral hemorrhage ranges from 0% (even in developed countries) to 20% of all patients.

In accordance with the European consensus meeting on the management of patients with stroke, held in 1995, Helsingborg (Sweden), on the basis of randomized kontroliruyushchego treatment of hemorrhagic stroke compared to conservative. Therefore, further research is needed on identifying the most informative and meaningful criteria for determining the appropriateness of surgical treatment of patients with primary intracerebral hemorrhage.

Search of determinants for the outcome of the disease that affect decision-making about treatment for a specific patient (medical or surgical) is reflected in numerous publications.

The treatment of patients with primary intracerebral hemorrhage are discussed in the book'clock P. Warlow and other "Stroke. A practical guide for the treatment of patients (translated from English.)" Ed. by D. M. N., Professor A. A. Skromna, St. Petersburg: University of technology, 1998, pp. 357-363 (copy attached). Based on the analysis of international publications, the authors provide information about the importance of certain characteristics (factors) that determine the prognosis of outcome in primary intracerebral hemorrhage supratentorial localization (state of consciousness [on a Scale Glasgow Coma], age, hematoma volume, penetration of the blood in the ventricles). The authors of this monograph also describe the General methods of treatment of patients, compare the available literature data on outcomes when possible, as a method of prediction of outcome after surgical form of treatment.

In the monograph by A. P. Romodanov, G. A., Pedachenko Brain hemorrhagic stroke", "Health", Kiev, 1971, in the section "Indications and contraindications for surgical treatment of patients with hemorrhagic stroke" (pp. 175-187) the authors analyze their own observations of the treatment of 230 patients with literature data on selection criteria (criteria determining the choice of treatment method and outcome of the disease. A. P. Romodanov, and P. Pedachenko distinguish progressive deterioration of patients with threatening appearance of symptoms (disorders of respiration and circulation, increased temperature, increased blood pressure), a progressive increase of intracranial hypertension, impairment of consciousness, age, localization of bleeding (large hemispheres of the brain, or cerebellum), breakthrough of blood in the ventricles of the brain, the severity of concomitant pathology of internal organs. In the monograph there are no gradations of these prognostic signs and the algorithm predict the outcome of drug therapy and surgical treatment.

In the recently published monograph centuries Lebedev, V. C. Krylov Emergency surgery. M, Medicine, 2000, the treatment Boer. 516 the authors 6 of the basic provisions governing the testimony of the surgical treatment: 1. The unsatisfactory results of conservative treatment, high mortality, especially in the acute period after the occurrence of intracerebral hemorrhage.

2. Increasing the compression of the brain caused by intracerebral hematoma and progressive perifocal edema.

3. Danger of breaking the blood of intracerebral focus of hemorrhage into the ventricular system.

4. The constant threat of dislocation lesions of the brain stem.

5. Adverse effects of the source of hemorrhage in cerebral blood flow with the deterioration of microcirculation and possible development of diapedetic hemorrhage in the cerebral hemispheres and stem structures.

6. The reversibility of perifocal and cerebral abnormalities that occur in the first hours and days after a stroke, if intracerebral hematoma evacuated before the development of irreversible changes in the brain stem.

These authors are General guidelines, there are no clearly selected prognostic criteria, their values for patients of different age groups and the algorithm to predict the outcome of treatment.

The closest solution is agnostic and treatment of intracranial arterial aneurysms in acute hemorrhage". M , Medicine, 1996, pp. 100-103 (copy attached). The book gives a list of the most informative factors (attributes) and their gradations that using the mathematical method of linear discriminant analysis allowed us to obtain the formula (decision rule) for calculating prediction of outcome of open surgery in patients in the acute period of the Cheka aneurysmal nature. The prediction of outcome of surgical treatment consisted of an analysis of 10 preoperative characteristics, including age (X1), hypertension (X2), EEG changes (X3), intracranial hematoma (X4), vascular spasm (X5), under the area of operations and area of vascular spasm (X6), the severity of the condition [on the hunt and Hess] (X7), the timing of the operation from the moment of rupture of the aneurysm (X8), the size of the aneurysm (X9), level of consciousness before the operation (X10), the determination of the coefficients of importance of the characteristics and development of formulas of the form: Y= -0,021X1+(-0,086)X2+(-1,374)X3+0,023X4+0,034X5+, 127X6+(-1,934X7+0,076X0 - 74,2%. The correct prediction of the outcome of the transactions tested on 91 sick.

The proposed method for predicting the outcome of surgical treatment was developed for patients with intracranial hemorrhage aneurysmal nature. In this way there is no account of the values of prediction characteristics for different age groups of patients.

The content of our work is the selection of prognostic features and their values in the method for predicting the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period.

The objective of the proposed method for predicting the development and introduction into clinical practice of a simple and reliable method for predicting the outcomes of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period.

To solve the problem in the method for predicting the outcome of surgical Les the acute period, based on the identification and analysis of the characteristic signs of the disease, analyzing the combination of prognostically relevant attributes, including the severity of somatic pathology (X1), a clinical-anatomical shape hemorrhage (X2), intracranial hypertension (X3), hydrocephaly (X4), the patient's condition on the day of surgery (X5), the timing of surgery after hemorrhage (X6) calculate the discriminant function Y according to the following formula: Y= 5,79+(-0,02)X1+0,74X2+(-0,59)X3+(-0,69)X4+(-1,34)X5+0,06X6. If the lookup data X1, X2,..., X6for a particular patient obtained a value of Y0, we predict a positive outcome of treatment, and if Y < 0 predict adverse outcomes.

The proposed method allows you to quickly and fairly high degree of confidence (63,6% in the group of surviving patients and 72.7% of deceased patients) to predict the outcome of surgical treatment. On the basis of such a predictor of outcome can Pania outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period included: 1) selection of prognostically relevant attributes, influencing the outcome of surgical treatment; 2) the use of a mathematical method, linear discriminant analysis, which allows us to identify the set of features that gives the highest percentage of favorable and unfavorable outcomes of operations to obtain the formula (decision rule), which allows to classify each patient to a particular group (1st group - survivors, the 2nd group - deceased), when you don't know to which group he belongs. The result of this method is linearly form (called discriminant function of the form: Y=C0+C1X1+C2X2+...CkXkwhere k is the number of signs; X0X1X2,..., Xk- characteristic values for a specific patient;
With0C1C2,... Ckthe coefficients of the characteristics that are defined in the application of the method of discriminant analysis.

If the lookup data X0X1, X2, Xk for a particular patient in a specified linear form obtained value Y0, then the patient is referred to the first group (the patient survived), if Y < 0 then the second (died).

In our case, the problem boils down to the fact that the doctor should Eisaku. In addition, when conducting discriminant analysis calculates the probability of misclassification for each group of patients, i.e. the probability that a patient from the first group can get to the second and Vice versa. Based on these probabilities it is possible to judge the reliability of the forecast (discrimination).

Statistical processing was performed on the PC AT "Pentium-233MMX on the basis of individually designed programs in the language "FORTRAN", using standard routines for the calculation of the discriminant analysis of mathematical software SSP. Correlation coefficients were considered significant different from 0 at P < 0.05 (for two-sided alternative).

The results of the study
The proposed method for predicting the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period was developed through analysis of 33 patients. Based on the data of the literature and our own clinical observations, to test hypotheses about the effect on the outcome of surgical treatment were selected 6 preoperative prognostic relevant attributes. Characteristic signs and their grades are presented in tah and deceased patients of middle age. In the result of the discriminant analysis identified the coefficients of the discriminant function corresponding to the selected features (With0-C6), whose values are given in table. 2.

In addition to obtaining estimates of the coefficients of the discriminant function was calculated probability of misclassification (i.e., the probability that the surviving patients may fall into the group of the deceased and Vice versa), which is characteristic of forecast reliability (table. 3).

From the data table.3 it follows that the probability of misclassification is 36.4% of the surviving patients and 27.3% of deceased patients. Therefore, the probability of correct prediction with the application of our method is 63.3% in the group of surviving patients operated and 72.7% of deceased patients.

When considering 6 preoperative signs we got discriminant function (decision rule) for prediction of outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in acute hemorrhage with:
Y= 5,79+(-0,02)X1+0,74X2+(-0,59)X3+(-0,69)X4+(-ub>6
- characteristic values for a specific patient (table. 1).

The Y value ofcorresponds to a favorable outcome, if Y < 0 - lethal. The probability of a favorable outcome when Y0 63,6%, and the probability of death when Y < 0 - 72,7%.

The efficiency of the method for predicting the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period illustrated by the following clinical examples.

Clinical example 1
Sick,, 58 years (and/b 11177/99 g), and entered on the 1st day of the Cheka, revealed intracerebral hematoma volume 148 ml hypertonic nature in parietotemporal lobes left without a breakthrough in the ventricles of the brain. Preoperative characteristics were the following: the severity of somatic pathology (X1) - 3 [pronounced due to GB III; coronary artery disease; coronary angiography, cardiac, cerebral atherosclerosis] , clinical-anatomic shape of the Cheka (X2) - 2 [intracranial hematoma type II] , intracranial hypertension (X3) - 3 [expressed], hydrocephalus (X4) - 2 [expressed], the severity of the condition on the day of surgery (X5) - 2 [subcompensated] , the timing of surgery after �232D/chr/8226.gif">2+0,742-0,593-0,692-1,342+0,062=2,24.

The value of Y > 0, so the outcome of the disease is likely to be favorable. Forecast confirmed - operation with the removal of intracerebral hematoma, the patient has recovered.

Clinical example 2
Patient B. , 55 (and/b 10622/99 g), and entered on the 1st day of the Cheka, revealed intracerebral hematoma volume 162 ml hypertonic nature in the deep sections of the left temporal lobe without a breakthrough in the ventricles of the brain. Preoperative characteristics were the following: the severity of somatic pathology (X1) - 3 [pronounced due to GB III; coronary artery disease; coronary angiography, cardiac, cerebral atherosclerosis] , clinical-anatomic shape of the Cheka (X2) - 2 [intracranial hematoma type II], intracranial hypertension (X3) - 4 [pronounced], hydrocephalus (X4) - 3 [pronounced], the severity of the condition on the day of surgery (X5) - 3 [asthma], the timing of surgery after hemorrhage (X6) -1 [1st day]. Substituting the data in the discriminant function, we get:
Y=5,79-0,022+0,743-0,594-0,69

Our research has shown that to predict the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period it is sufficient to analyze the combination of 6 preoperative symptoms: the severity of somatic pathology, clinical-anatomic shape hemorrhage, intracranial hypertension, hydrocephalus, the patient's condition on the day of surgery, timing of surgery after hemorrhage. Clarification of prognostically relevant attributes and their definition of the coefficients of discriminant functions for patients of middle age has allowed to determine the correctness of the prediction of outcome of surgical treatment in 68.2% of observations.


Claims

A method for predicting the outcome of surgical treatment of primary intracerebral hemorrhage supratentorial localization in patients of middle age in the acute period, including the identification and analysis of signs g src="https://img.russianpatents.com/chr/183.gif">X1+0,74X2+(-0,59)X3+

+(-0,69)X4+(-1,34)X5+0,06X6,

where X1- the severity of somatic pathology: 1 - missing or blurred expressed, 2 - severe, 3 - pronounced;

X2- clinical-anatomical shape hemorrhage: 1 - intracranial hematoma to 50 ml, not accompanied by dislocation of the brain, 2 - intracranial hematoma of more than 50 ml, accompanied by dislocation of the brain and/or occlusion or tamponade liquor-conducting tracts;

X3intracranial hypertension: 1 - absent, 2 - blurred expressed, 3 - severe, 4 - pronounced;

X4- hydrocephalus: 1 - absent, 2 - blurred expressed, 3 - pronounced;

X5- the severity of the patient's condition on the day of surgery: 1 - offset, 2 - subcompensated, 3 - decompensated;

X6- timing of surgery after hemorrhage: 1 - 0-3 days, 2 - 4-7 days, 3 - 8-14 days, 4 - 15-21 day 5 - more than 21 days, and when the value of The0 predicts favorable, and when The < 0 - lethal.

 

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