A method for predicting the course and outcome of the disease in patients in the acute period of ischemic stroke

 

(57) Abstract:

The invention relates to medicine, and neurology. Assess the patient's condition at the time of admission in the hospital on the 7th and 14th day. Register RR-kardiointervalogrammy. Handle time series of RR-R-R-interval, out from the 10-minute ECG records in the first standard lead. Estimate the standard deviation of the values of the R-interval, fractal parameters, respectively, for the Central nervous system (CNS) and the autonomic nervous system (ANS), the potential of self-organizing systems. Favorable prognosis, deterioration or critical threshold not compatible with life, predict the values of the measured parameters. The method allows to obtain data on the dynamic state before the objective changes of clinical symptoms.

The invention relates to medicine, specifically to neurology, and can be used to predict the course and outcome of the disease in the acute period of ischemic stroke.

Stroke annually affects the world's approximately 6 million people, and in Russia - more than 45 thousand According to the international epidemiological studies, every year in the world dies from a stroke 4.7 million h is Arnau pathology. Early (thirty-day) mortality is on average 35% and in the first year after onset of the disease is 50%. Stroke is one of the main causes of disability in the population. About 55% of patients by the end of the 3rd year of the disease are not satisfied with the quality of life. According to the international multicenter studies, among all types of strokes dominated by ischemic brain damage. The ratio of ischemic and hemorrhagic stroke is 5.0 to 5.5 to 1, that is 80-85 and 15-20%, respectively. Mixed stroke is 10%.

In connection with this important study of pathogenesis, diagnosis, course of stroke, as well as the possibility of predicting their outcomes. In the existing literature to date, little attention has been paid to predicting the course and outcome of the acute period of stroke, although the relevance of this issue of concern to many clinicians. Not clearly defined clinical and instrumental criteria, based on which a neurologist at the early stages of the disease will be able to evaluate the patient's condition, to predict the course and outcome of stroke. If previously the task of the researchers was to identify the main most reliable clinical with the period of the disease (N. With. Misiuk. Cerebral stroke. Prediction and prevention. - M., 1980), at the present time to solve this problem is actively using modern diagnostic methods: magnetic resonance imaging (MRI), computer tomography (CT), duplex scanning, etc.

The closest in technical essence and the achieved result is a method for predicting the course and outcome of the disease in patients in the acute period of ischemic stroke, including the assessment of the condition of the patient (Including P. Warlow, M. S. Dennis coauthors. The stroke. A practical guide for the management of patients. - SPb.: Polytechnic, 1998).

The disadvantage of this method of forecasting is its low reliability. To date, despite numerous studies, not installed base of clinical and instrumental criteria that can help the neurologist in predicting disease outcome in patients in the acute period of ischemic stroke.

The technical result, which directed this invention is to improve the accuracy and reliability of predicting the course and outcome of the disease in patients in the acute period of ischemic stroke. Given the patients in the acute period of ischemic stroke, including the assessment of the condition of the patient, according to the invention the evaluation of the patient is performed at the time of admission in the hospital on the 7th and 14th day method RR-cardiointervals. During this process the time series of RR-R-R-interval, out from the 10-minute ECG records in the first standard lead, digitized with a sampling frequency of 160 Hz.

It was estimated following integral parameters of systemic regulation: ,1,2and U

where the parameter is normalized with respect to the age standard deviation of the values of the R-interval characterizing the voltage stochastic components of homeostasis of the organism and reflecting its energostrukturu adaptation costs;

1, 2- fractal parameters, respectively, for the Central nervous system (CNS) and the autonomic nervous system (ANS);

U is the potential of self-organizing systems (potential homeostasis of the Central nervous system).

This feature allows you to define a measure of the risk of loss of stability of the investigated functional system or, on the contrary, reflects the tendency of normalization with adequate therapy, while if the value =1,0; 1< or=0.6;1,2=0.6 and U=0,85 predict worsening status the major diagnostic criteria for predicting the course and outcome of the disease in patients in the acute period of ischemic stroke, using the method of computer-assisted rapid analysis of the duration of RR-R-R-interval. (Muzalevskaya N. And., Uritsky C. M. Stochastic methods of functional diagnostics and correction in medicine. Telemedicine: new information technologies on the threshold of the 21st century/ edited by R. M. Yusupov, R. I. Polovnikova. SPb. - 1998, S. 209-243, Uritsky Century M a software Package for the isolation and analysis of the fluctuations of RR-cardiointervals (1999-2001) // Uritsky @ pop600.gsfc.nasa.gov.)

In this regard, the following tasks were solved:

1 - statistical, spectral and fractal analysis of variations of RR-R-R-interval in patients in the acute period;

2 - determining the severity of the condition, predict the course and outcome of a disease based on the mapping and synthesis of data from the perspective of the concept of optimum stochastic homeostasis;

3 - evaluation of the functional activity of the Central nervous system (CNS) activity reflected in the field of ULF spectrum of the autonomic nervous system (ANS): the sympathetic (LF region) and parasympathetic (HF region of the spectrum) departments. The nature of changes in their activity in the course of the disease.

Method cardiointervals based on the analysis of frequency-time is coy physiology and theory of nonlinear interactive systems.

Material for analysis was serving time series of RR-R-R-interval, out from the 10-minute ECG records in the first standard lead, digitized with a sampling frequency of 160 Hz. The study was conducted at the time of admission to the hospital, 7-and 14-day, and as the deterioration in patients with lethal outcome.

It was estimated following integral parameters of systemic regulation:

The parameter is normalized with respect to the age standard deviation of the values of the R-interval characterizing the voltage stochastic components of homeostasis of the organism and reflecting its energostrukturu adaptation costs. With age, the value of the option decreases, reflecting the natural energostrukturu involution of the body. Criterion standards, according to the concept of stochastic homeostasis is a state of optimum self-organizing system that characterizes value =1,00. Its reduction to the level of <0,6 indicates the occurrence of rigid heart rhythm, which is a predictor of risk. The smaller the parameter is, the higher the probability of occurrence of critical conditions. Increase >of 1.00 indicates an increase adaptive activity Orc arrhythmia.

The degree of integrative processes in the CNS and ANS reflect1,2-fractal parameters respectively for the CNS and ANS, are determined using the method of Peng. Functional optimum regulation of homeostasis of the system is achieved when the values of these parameters 1,00. The physiological range corresponding to a normal adaptive response: 1<<0,6 arise disintegration, and then the chaotization of the systemic linkages, leading to the violation of the existing system hierarchy. When values of >1,6 transition to the mode hyperintegration, which is characterized by rigidity regulation modes. In both cases, the system loses its adaptive stability, which is an adverse prognostic factor.

To quantify the risk and the tendency to normalization with adequate therapy allows the parameter U is the potential of self-organizing systems (potential homeostasis of the CNS). This characteristic determines the stability of the investigated functional system. Calculation and statistical observations show that in healthy people the physiological range of variation of potential: 0,85<U<1,0.

U=and-0.6 - critical threshold not compatible with life.

S-ULF - relative spectral power in low frequency ranges, reflecting the activity of the Central nervous system.

S-LF; S-HF - relative spectral power in the range of low and high frequencies, reflecting the activity of the sympathetic and parasympathetic divisions of the ANS.

We studied 80 patients who were in acute period of ischemic stroke. Men 46 women, 34, aged from 31 to 85 years, mean age 612 years.

In the future, all patients were divided into 2 main groups:

group 1 - patients with a favorable outcome of the disease (70 people);

group 2 - all patients had a fatal outcome (10).

Viewing 1 group, it may be noted that it is dominated by patients carrying onmk first 65 people and 5 people - again. Patients from group 2 suffered cerebral vascular accident for the first time.

Dynamics of changes in neurological symptoms: patients from group 1 had a stable positive dynamics since the first week of the disease, a complete regression of cerebral symptoms, and the majority (42) a significant decrease in ochanoko rise and focal cerebral symptoms, which ultimately resulted in death.

According to CT scan in the first group was dominated by patients with 1 ischemic lesion of small and medium sized 45. 25 people had 2 or more of the hearth. Localization was predominantly subcortical and deep brain areas. In the 2nd group noted the extensive ischemic foci in several parts simultaneously in the subcortical and deep divisions.

Common to both groups of patients during the first days of the disease was a significant change most of the parameters of the method RR-cardiointervals. The most informative at this stage of research we presented changes in the following indicators: decrease in the fractal1that indicates disintegration, but with a further reduction and chaotization of systemic connections in the Central nervous system, the prevalence of uncompensated costs homeostasis and imbalance of systemic regulation. When the comparison of the dynamics of changes1between 1 and 2 groups is indicative that in group 2 index1already in the early acute period was significantly lower. Subsequently it has been further reduced, which indicates the increase of the x was marked opposite dynamics: at the beginning of the 2nd week there was a trend toward normalization of values, indicating the transition from the chaotization to system integration, increased activity of the Central nervous system (S-ULF).

With regard to changes in index of fractality 2that reflects the integrative function of the ANS and indicates an adequate adaptive response within the range of physiological norm: 0,85<2began to decline sharply, pointing to the distinct processes of chaotization, and 62% showed a significant excess of normal values2>>1.0, which indicates the system mode hyperintegration. In these modes, there is an infringement of processes of system hierarchy, overload of all adaptation mechanisms, and biological system, in such condition, extremely vulnerable. So it is common to both groups at the beginning of the disease are expressed in the processes of system disintegration occurring in the Central nervous system on the background of the adaptive voltage autonomic managers. Subsequently, in group 1 there is a tendency to normalization of the values of the indicators, while in the 2nd group on the background of the deepening of the processes of chaotization in the Central nervous system (further reduction1) there is a lack of integration processes in the vegetative is the predictive relationship can be said about the parameter , which is independent of the fractal index, risk factor.

In the 1st group of patients at disease onset is dominated by normal and moderately elevated values. Only a small group (10%), which included patients with recurrent stroke and diabetes, reduced values. By the end of the acute period observed a clear trend toward normalization of this index, which reflects adequate activation adaptation reserve and trophic nervous tissue. This creates positive conditions for recovery. Patients of the 2 groups of metric values at the beginning of the disease are beyond the range of the physiological norm. They are either significantly below or exceed it. In the dynamics of observations is accentures more clearly, which indicates that the critical reduction energostrukturu opportunities homeostasis and deviation either side of the rigid mode of the cardiac rhythm, or Vice versa, labile, with the transition to unstable rhythm, accompanied by the increase of symptoms of heart failure.

Considering the changes U-potential self-organizing system (CNS homeostasis), it should be noted that at the beginning of the disease was noted sushestvenno level of 0.6, describing an unstable balance of adaptation costs and compensatory replacement.

In the 2nd group already at the initial stage of the disease, the average values of U=0.270,13 indicate expressed uncompensated costs of the body and an increased risk of adverse outcome of the disease. Further dynamics of indicators reflects a trend of recovery in patients of the 1st group: significant increase in the average values of U up to 0.750.06 and critical deterioration in group 2, as evidenced by the transition of values in the region of negative values: U=-0,08; -0,65 a few hours before death, that U<<of-0.62 (critical threshold). The rate of activity of the Central nervous system: S-ULF also showed a steady decline in group 2, and in patients from group 1, being moderately reduced in the initial stages of the disease, further tended to normalize.

As an example, we consider two patients of the 1st and 2nd groups. The patient subsequently was discharged on the 19th day from the hospital with the improvement, the patient was noted to death, on the 7th day from the beginning of the disease. Common for patients a and b at the beginning of the disease was marked reduction of the majority of indicators met that pointed to an adequate increase energostrukturu costs and reduce the adaptive resistance of the organism, and disintegration processes in the Central nervous system. The index of fractality2=1,64 above normal value, which characterizes the mode hyperintegration autonomic nervous system. By the end of the second week of this patient has been a trend toward normalization of indicators: =0,97;1=1,09; U=0,94;2=1,21. In contrast to the patient And the patient in the first hours of the disease the majority of the indicators were much lower: =0,58,1=0,50, U=0,32. It pointed to the prevalence of uncorrected energy consumption, decreasing adaptation of sustainability and the process of chaotization in the Central nervous system. Index of fractality2=1,15 remained within the physiological range of values that indicated an active integration processes in the autonomic nervous system. In the dynamics on the fourth day of the disease was marked by a clear tendency to decline, which was unfavorable prognostic sign. By the end of the first week of illness values has reached a critical level incompatible with life: =0,21;1=-0,32, U=-0,59. Death of the patient was observed on the seventh day from the beginning of the disease diagnosis risk (, U, S-ULF, S-LF, S-HF,1,2) allow you to retrieve information about the dynamics of state before the objective changes of clinical symptoms and to predict the possible outcome of the disease. At the beginning of the disease characterized by reduced integration (1) and activity (S-ULF) of the Central nervous system at the beginning of the stroke, with preserved activity of the sympathetic and parasympathetic parts of the autonomic (2). Further, when the recovery of the patients had a trend toward normalization of indicators, whereas in the case of death we observed a reduction to critical values, not compatible with life.

The proposed method of predicting the course and outcome of the disease in patients in the acute period of ischemic stroke is by far the most accurate and reliable in comparison with known methods.

A method for predicting the course and outcome of the disease in patients in the acute period of ischemic stroke, including the assessment of the condition of the patient, characterized in that the evaluation of the patient is performed at the time of admission in the hospital on the 7th and 14th day method RR-cardiointervals, during this process the time series of RR-R-R-interval, vydelavat the m evaluate the following integral parameters of systemic regulation: , 1, 2 and U, where the parameter is normalized with respect to the age standard deviation of the values of the R-interval characterizing the voltage scholastic components homeostasis and reflecting its energostrukturu adaptation costs; 1, 2 - fractal parameters, respectively, for the Central nervous system (CNS) and the autonomic nervous system (ANS); U is the potential of self-organizing systems (potential homeostasis of the CNS), while the values =1,0; 1<=1,6; 1,2=0.6 and U=0,85 predict deterioration, and if U=and-0.6 critical threshold, incompatible with life.

 

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