The method of evaluation of the provision of collateral circulation in patients with cerebral ischemia

 

The invention relates to medicine, namely to functional diagnostics and neurophysiology. Assess the dynamics of electroencephalogram (EEG) and neurological status before and after diagnostic tests. As samples are blockade upper sympathetic ganglion on the side of the affected vascular pool. When detecting regression noted in the original EEG changes and neurological fallout assess the provision of collateral circulation intact, and if there are no changes or augmentation of pathological changes in the EEG and neurological status without dynamics or neurological fallout appreciate how the lack of provision of collateral circulation. The method allows to increase the reliability of the test. 6 Il.

The invention relates to medicine, namely to functional diagnostics and neurophysiology, and can be used to estimate the reserve capacity of collateral circulation in patients with cerebral ischemia to determine the choice of optimal treatment: a course of blockages or definition of the indications for surgery (sympathectomy with the definition of the hand surgical vmeste the moral of brain blood flow in patients with cerebral ischemia (M. Phelps, Maziotta J., Shelbert J. Positron emission tomography and autoradiography: Principles and applications for the Brain and Heart. N. Y., Raven Press, 1986, 350 C.), consisting in the direct assessment of perfusion of the brain by methods of single photon emission computed tomography (SPECT), positron emission tomography (PET) with acetazolamide test. The disadvantages of this method are the high cost of equipment, the use of short-lived radioactive isotopes that require special protection of personnel. In this regard, the use of research in patients limited by low availability of equipment, lack of mobility. It is impossible widespread use for screening in groups, stroke risk, limited opportunities for observation of patients in the dynamics and load tests.

There is a method of assessment of the provision of collateral circulation in patients with cerebral ischemia (Newell D., Aaslid Century Transcranial doppler. N. Y., Raven press, 1992, 230 C.) - transcranial Doppler (UCD) with compression samples, consisting of indirect estimation by varying the linear velocity of blood flow, pulsatile index and other indicators kinematics of blood flow in cerebral arteries. The disadvantages of this method are the large errors in the determination of the parameters, sasisasi and brain matter.

There is a method of assessment of collateral circulation in patients with cerebral ischemia (smigelski A. C. Infrared spectroscopy of the brain in early detection of cerebral ischemia during operations in neurosurgical patients with vascular brain pathology. Abstract. Diss. Kida. the honey. Sciences. M., 1998, S. 22), including spectrophotometry in the range close to infrared and lies in the indirect assessment of perfusion of the brain to change metabolism.

The disadvantage of this method is the possibility of only local estimates of metabolism and indirect assessment of local perfusion in the location of the sensor without presentation about systematic changes in the brain as a whole.

Closest to the claimed method is a method of assessment of the provision of collateral circulation using electroencephalographic (EEG) methods to assess the functional significance of cerebral arteries in occlusal functional test to address the question about the possibility of a shutdown of blood flow cerebral arteries (Benashvili, M. Treatment of giant intracranial arterial aneurysms. Diss... Kida. the honey. Sciences. L., 1989, S. 187) adopted for the prototype. The method consists in the registration of EEG before about the kind of symptoms and EEG changes. When focal neurological symptoms and EEG changes in the area of perfusion of the occluded artery it is considered significant functional without reserve collateral circulation. Balloon occlusion of the artery produced in x-ray operating by catheterization of the femoral artery by the Seldinger, holding balloon-catheter in the carotid artery on the neck under the control of the electro-optical Converter (Tube) using angioscopy with contrast substance.

The disadvantages of the prototype are: the invasiveness of the method, increasing the trauma, increasing the risk of complications associated with the introduction of a foreign body (catheter and balloon) and a contrast agent in the arterial tree; the need for x-ray control with the use of stationary expensive equipment and exposure of the patient and personnel; the technical difficulty of performing occlusion requiring high qualifications of the researcher, the need for hospitalization, use of anesthesia.

The invention is directed to a method of evaluation of the provision of collateral circulation in patients with cerebral ischemia, preventing injury outpatient survey staff using commodity hardware General hospital or diagnostic center.

The method consists in the following: based on the assessment of neurological status of the patient with cerebral ischemia and changes in the dynamics of EEG before and after blockade of sympathetic ganglia in the neck produce indirect estimates of reserve collateral circulation of the patient.

The inventive method differs from the prototype in that conduct the blockade of sympathetic ganglia and orientation dynamics of EEG and neurological status assess the provision of collateral circulation.

The method is as follows: the patient write scalloway multichannel EEG (usually 16-channel) ink-writing the electroencephalograph. Chlorine-silver polarizadas electrodes impose on standard international methodology "10-20" registered potential by averaging (time constant 0.3 s, the filters 60 Hz, the speed tape drives 30 mm/s) with registration potentials using any version of commutation.

Assessment of EEG produce visually on generally accepted in clinical practice the technique. This conclusion is descriptive. Estimated dominant - basic rhythm on the period, amplitude, shape, distribution convexo that PUR, disorders of cortical-subcortical interactions, the safety of neurodynamics crust, hemispheric asymmetry, focal process. Quantify the frequency and duration of outbreaks and paroxysmal activity.

Spend the blockade of sympathetic ganglia with the use of local anesthetics (novocaine, lidocaine) by standard methods, controlled by the appearance of the syndrome Horner on the corresponding side.

After blockade continue the registration of EEG. Assessment of neurological status is carried out according to the classic method, at the same time paying attention to the presence of focal symptoms and its dynamics after the siege.

Comparative analysis of changes in the EEG before and after blockade allows you to select the following changes:

1. Positive dynamics, if procaine blockade leads to a distinct regression noted in the original recording of EEG changes, regression of neurological deficiency.

2. No effect means the inability to visually identify reliable unidirectional changes of EEG, neurological status is unchanged.

3. A negative result, if after conducting a blockade grow pathological changes in EEG any structrual clinical trials for the examination of 16 patients. The effect of analgesia was assessed comprehensively. On the basis of the received EEG changes and dynamics of the neurological status of the patients were classified into 3 groups described above, which allowed us to assess the provision of collateral circulation and to determine adequate treatment of patients.

Patients of the first group was conducted in a course of blocks sympathetic ganglion or sympathectomy side received positive change. Marked by good clinical effect of the course of blocks and surgical treatment in patients with stenocereus processes of the main vessels of the head in the immediate postoperative period and one year after the intervention.

In patients 2 and 3 groups the result of the blockades had no or negative. While patients 3 groups when conducting blockades developed the syndrome victimize and observed deterioration with development of neurological symptoms, which was confirmed and the corresponding negative dynamics of the EEG data. Holding sympathectomy in patients of these two groups is not recommended due to the possibility of deepening neurological deficit.

Examples of extracts from the histories.

Example 1. Patient B., born in 1983, re-organized the>/p>20.03.98 patient suffered a hemorrhage in the left lateral ventricle of the brain with subsequent development within 2 weeks deep left-sided hemiparesis. 09.04.98 MRI brain revealed an ischemic focus in the right hemisphere subcortical departments and in the cortex parietal-occipital region. On a series of positron emission tomograms with the radiopharmaceutical water (15About) revealed a sharp decrease in blood flow in the con-oxytelinae cortex right temporal and parietal lobes.

According to the claimed method were recorded EEG (Fig.1), then conducted the blockade of the cervical sympathetic ganglia on the right, which was monitored by the appearance of the syndrome Horner on the side of the blockade with the registration of the EEG (Fig.2). In scalloway EEG increase the frequency of the alpha rhythm. On the basis of the dynamics of EEG patient was assigned to the 1st group - positive reaction to the blockade. Thus, it is possible to judge saved the provision of collateral circulation on the side of ischemia. At first hospitalization in 1998 he received a course of vascular therapy and blockade of the cervical sympathetic ganglia on the right. After a course of blocks marked regression of paresis of the left foot.

16.04.99 the patient had an operation: vernesa restore deep muscle and joint sense in the left hand, regression paresis in it to 4.5 points, the appearance of fine precise movements of the fingers, the expansion of the field of view to the left.

Currently, the patient is studying in College, focal neurological deficit (excluding syndrome Horner after periarterial decimalization right).

Example 2. Patient H., 42 years history No. 2128/00.

In September 1999, gradually increasing weakness of the right limbs and speech disorders. The identified elements mixed aphasia, mild right-sided hemiparesis to 4 points in the brush, the smoothness of the right nasolabial fold.

On computer tomography brain is determined postischemic cyst in segnetoelektrikakh departments left parietal lobe, moderate hydrocephalus. On angiograms - thrombosis of the left ICA from the level of bifurcation of the WASP.

The patient was registered EEG (Fig.3), then produced a blockade of the cervical sympathetic ganglia on the left, which was monitored by the appearance of a distinct syndrome of Horner left, after which re-registration of EEG (Fig.4). In scalloway EEG without reliable functionally important dynamics. Patient assigned to the 2nd group with the almost complete lack of provision of collateral circulation, which confirmed the ganglion. A course of vascular infusion therapy and 15.11.00 operation: ligation of the superior thyroid and lingual artery to the left (centralization of blood flow in the left NSA) and the cervical sympathectomy on the left. In the postoperative period, there has been only a slight decrease opticheskih disorders preserving spastic hemiparesis. In the postoperative period remains neurological deficit, defined disability group I at the time of examination in the category.

Example 3. Patient L., aged 44, story No. 1169/99. Ill acutely 17.06.99, when he developed a deep left-side hemiparesis, speech disturbance. Angiographic examination revealed thrombosis of the right ICA, and MRI brain - cystic changes in the right temporal and parietal lobes.

Patient registered EEG prior to the blockade of the cervical sympathetic ganglion to the right (Fig.5) and after blockade (Fig.6). Visually reveals the growing phenomena of distant synchronization with the deepening of inter-hemispheric asymmetry. On the basis of the dynamics of EEG patient assigned to the 3rd group, i.e. the provision of collateral circulation is absent, hemodynamic changes after blockade, manifested neurological deficit after any Doppler before and after blockade (increase BFV and decreased PI in the blood vessels of the right hemisphere of the brain, in the pool right ACA) effect of analgesia was assessed as positive and patient 21.07.99 transaction: arteriotomy right ICA, cervical sympathectomy on the right. In the postoperative period marked the development of paresis of the IX and X cranial nerves left, hypersalivation, deep left-side hemiparesis 1-2 points in hand, 2-3 points in the leg), the preservation of deep sensing disturbances in the left limb, the elements of motor aphasia. The patient received a massive infusion of vascular and neuroprotective therapy, but he remained pronounced neurological deficit.

Thus, the inventive method is non-invasive, sensitive, widely available, portable and low-cost method of valuation reserves of collateral circulation in patients with cerebral ischemia of stenosing lesions of the brain.

Claims

The method of evaluation of the provision of collateral circulation in patients with cerebral ischemia, including assessment of the dynamics of electroencephalogram (EEG) and neurological status before and after diagnostic specimens, characterized in that the quality of the sample conducted the blockade of the upper sympathetic ganglion on the side of the affected vascular preserv collateral circulation intact, and if there are no changes or augmentation of pathological changes in the EEG and neurological status unchanged or rise of neurological deficiency is assessed as the lack of provision of collateral circulation.

 

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FIELD: medicine, neurology, psychopathology, neurosurgery, neurophysiology, experimental neurobiology.

SUBSTANCE: one should simultaneously register electroencephalogram (EEG) to detect the level of constant potential (LCP). At LCP negativization and increased EEG power one should detect depolarizational activation of neurons and enhanced metabolism. At LCP negativization and decreased EEG power - depolarized inhibition of neurons and metabolism suppression. At LCP positivation and increased EEG power - either repolarized or hyperpolarized activation of neurons and enhanced metabolism. At LCP positivation and decreased EEG power - hyperpolarized suppression of neurons and decreased metabolism of nervous tissue. The method enables to correctly detect therapeutic tactics due to simultaneous LCP and EEG registration that enables to differentiate transition from one functional and metabolic state into another.

EFFECT: higher accuracy of diagnostics.

5 dwg, 1 ex, 1 tbl

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