Method for determining intraoperation trigeminocardial reflex risk degree in patients suffering from vestibular neuroschwannoma

FIELD: medicine.

SUBSTANCE: method involves carrying out clinical and diagnostic examination and additionally measuring latent period of III peak on invoked potential curve from acoustic invoked stem potentials. Cerebral stem injuries are determined from neuromuscular electrodiagnostic data. Latent period III peak value being above or below a norm and injured medial cerebral stem region allover the stem thickness or totally injured lateral and caudal stem regions or all said regions injury taking place, high intraoperation trigeminocardial reflex risk degree is diagnosed in patients suffering from vestibular neuroschwannoma. Latent period III peak value being above or below a norm and no injuries of cerebral stem or latent period III peak value corresponding to norm and totally injured lateral and caudal stem regions at the same time or only medial cerebral stem regions taking place, moderate risk degree is diagnosed. Normal latent period III peak value and no injuries of cerebral stem being the case, low risk degree is to be diagnosed.

EFFECT: high accuracy of diagnosis.

 

The invention relates to medicine and can be used in the treatment of parastem tumors.

Trigemino-cardiac reflex (TCR) is a well - known reflex, which is manifested by bradycardia, arterial hypotension, apnea and enhanced perestaltic stomach. There is also a more rare version of the manifestations of the TCR, which is reflected in the pronounced rise HELL systolic (up to 180 mm Hg and above) and diastolic (up to 100 mm Hg and above). At the present stage it is desirable to determine the risk of intraoperative trigemino-cardiac reflex in the preoperative stage and carry out its prevention, as bradycardia, hypotension and hypertension entail hypoperfusion, expressed bleeding, leading to the development of ischemic disorders in the brain. In addition, knowledge of the risk of intraoperative TKR can be used as a measure of expediency total or Subtotal removal of vestibular sanomi (TS).

Known attempts to map the data ASWP (acoustic stem evoked potentials) in patients with life data about the level of the lesion in the brain stem, obtained at autopsy (James J. Stockard, M. D., Ph. D., and Valerie S. Rossiter, M. A. Neurology 27: 316-325, April 1977).

The disadvantage of this method is that the comparative analysis was carried out with posmart the m material, but then not used for pre-operative lifetime prediction.

Known way to assess risk factors for intraoperative development TKR in patients with vestibular schwannomas, including clinical diagnosticheskih research. Risk factors include: hypercapnia, hypoxemia, insufficient depth of anesthesia, i.e. pain, age of patients, characteristics of the stimulus (strength, duration, and so on), taking certain medications (beta-blockers, calcium channel blockers, drugs). Conduct research clinical diagnostic indicators: gender, weight, known history of heart arrhythmia, thyroid disease, preoperative arterial hypotension, heart rate, mean blood pressure (Bernard M. D. Schall et al. Journal of neurosurgery, V. 5, Issue 3, Article 5, 1998, prototype)

The disadvantages of the presented predictive method are used for the forecast is mainly clinical data, lack of data about the state of the brain stem, and data on the size of the HS, which reduces the accuracy of the prediction. It is based mainly on the presence of arrhythmias in the preoperative period or just the patients taking antiarrhythmic drugs, it is not possible to diagnose the severity of disorders in the brain stem.

The present invention is to eliminate the giving of these shortcomings through a deeper study of the brain stem, enabling a more accurate estimate of the volume of his defeat and spend adequate therapy in the preoperative period.

For this purpose, the method of determining the risk of intraoperative development trigemino-cardiac reflex in patients with vestibular Swannanoa, including clinical diagnosticheskih research suggested further electrophysiological studies, with acoustic stem brainstem to measure the latent period III peak on the curve evoked potentials, and nerve-muscle electric diagnostics (NMA) to determine the lesion of the brain stem, and when the indicator latent period III peak above or below normal and lesion of the medial divisions of the brain stem through the entire thickness of the trunk, or the total defeat of the lateral and caudal divisions of the trunk, or the defeat of all of these departments to diagnose a high degree of risk. When the indicator of the latent period III peak above or below normal and the absence of lesions of the divisions of the brain stem, or if the indicator latent period III the maximum norm and the defeat of the medial division of the brain stem, the entire thickness together with lesions of the lateral and caudal divisions of the trunk at the same time or the loss of the medial segments of the stem to diagnose average article the stump risk and under normal indicator latent period III peak and the absence of lesions of the trunk to diagnose low risk.

The method is as follows.

On admission the patient in the neurosurgical Department conducts clinical and diagnostic research, which include the examination of organs and systems, assessment of neurological status, radiographic, ECG, blood pressure measurement, inspection otonevrologa, neuroophthalmology and advanced electrophysiological studies, such as neuromuscular electric diagnostics (NMA) and acoustic stem evoked potentials (ASWP).

NMA is carried out on the spacecraft Mymodel-10” according to the following procedure: stimulation produced at the point of output I, II, III branches of the trigeminal nerve on the side of the tumor and the opposite side, and the exit point VII of the parties. For stimulation is applied exponential current frequency of 1 Hz, a constant duration of stimulus 200 MS, current from 0.05 to 6 mA. The current is gradually increased until you feel light in the eyes of the patient (first party causing irritation and then contralaterally side) or until visually detectable reduction in the circular muscle of the eye. During stimulation I and II of the branches is determined by early and late blink reflex response (Mr), when the stimulus is tion III branch - only early response. For a complete elimination of the pathology of peripheral nerve branches determine elektrovojvodina the peripheral branches of the facial and trigeminal nerves and facial muscles. Normal current for an early component of MP 1.2 mA±0.2 mA normal current to obtain late Mr component is 2 mA±0.2 mA normal current to obtain muscle response when applying irritation at the point of exit of the VII nerve is 1.1 mA±0.2 mA. Based on these results establish violations in the brain stem, while the total score by which to judge the depth of lesions of the trunk and to assess the risk of TKR.

Check conduction of electric current in different departments is as follows.

Detection of altered parameters power supply for receiving a response at the stimulation point out of the trunk of VII nerve indicates a lesion of the lateral part of the Department of the barrel, which includes the core of the VII nerve and adjacent to it the area of the brain stem to the left or right depending on the side of the irritation.

Registration of changes in indicators of current during stimulation of branches of the fifth nerve with preservation or minor change indicators current to obtain a late answer MRI shows lesions

latera is lnyh and caudal divisions of the barrel, covering the bridge, engine V, VII, X, IX nerves to the right or left depending on the side of the irritation.

Measurement of change of current to obtain a response at the stimulation I and II branches of the fifth nerve is: the change of the current or the preservation of normal values of current for an early component of the response at Mr unilateral stimulation on the side of the tumor and the absence of late component or abrupt change indicators current to obtain a late component indicates advanced lesions of the brain stem, which covers the medial sections of the brain stem, through the entire thickness of the brain stem is the area of the reticular formation, when applying the stimulus to the right or to the left;

ASWP the study was conducted on the diagnostic software to Neuro-MEP 2” firm “Neurosoft”. The active electrode is set at the vertex, having reference to the mastoid process, the ground electrode on the forehead. Use alternate monoarticular stimulation in the form of clicking a duration of 1 MS rectangular shape. Polarity clicks alternative. The intensity of the stimulus - 90 dB, frequency of stimulus injection of 10 Hz, the analysis epoch - 10 MS, number of averages - 2000. Assess the value of the latent period III peak. On the latent period of peak III judge the condition of the caudal division of the bridge, the top is about olivanova complex and oral departments of the medulla oblongata, in this zone are the autonomic centers of the regulation of respiration, blood pressure, cardiac activity, vascular tone, etc. In the normal latent period III peak of 3.9-4.1 MS. Lengthening or shortening of the latent period III peak indicates the defeat of the above divisions of the brain stem and is a bad prognostic sign.

According to the results of the above studies, there are three degrees of risk of developing intraoperative TKR: high, medium and low.

When the indicator of the latent period III peak above or below normal and lesion of the medial segments of the stem, or the total defeat of the lateral and caudal divisions of the trunk, or all departments of the barrel simultaneously diagnosed with a high degree of risk. When the indicator of the latent period III peak above or below normal and the absence of lesions of the brain stem, or if the indicator latent period III the maximum norm and the defeat of all departments of the barrel, or just medial divisions of the trunk diagnose average degree of risk. Under normal indicator latent period III peak and the absence of lesions of the brain stem diagnosed with low risk.

Example 1

Sick So 52 years. The diagnosis of vestibular Sanoma right. In the preoperative period, patients received NMA and ASIT.

NME vypolnyala apparatus “Mymodel-10”, produced stimulation in the exit points I, II, III branches of the trigeminal nerve on the side of the tumor and the opposite side. For stimulation we used the exponential current frequency of 1 Hz, a constant duration of stimulus 200 MS. The current is gradually increased until you feel light in the eyes of the patient (first party causing irritation, and then on the contralateral side). Power supply for an early component of the blink reflex irritation when I branch of the fifth nerve was right to 1.2 mA, to the left of 1.0 mA, the stimulation II branch to the right of 0.8 mA, left, 0.8 mA, to obtain late Mr component force of the current was to the right of 2.4 mA, left to 3.0 mA. To obtain muscle response during stimulation of the exit point of the VII nerve current was right to 2.6 mA, left 1.2 mA. Thus, damaged all departments of the trunk.

ASIT performed on diagnostic software Neuro-MEP 2” firm “Neurosoft”. The active electrode was placed on the vertex, having reference to the mastoid process, the ground electrode on the forehead. Used alternate monoarticular stimulation in the form of clicking a duration of 1 MS rectangular shape. Polarity-click alternative. The intensity of the stimulus - 90 dB, frequency of stimulus injection of 10 Hz, the analysis epoch - 10 MS, number of averages - 2000. Estimated value of the latent period III peak. The disturbances which prolong the latent period of peak III from the norm was +24.6 percent. The risk of TKR - high. Operations developed TKR. The patient died in the postoperative period.

Example 2

Patient O. 64 years. The diagnosis of vestibular Sanoma left. According to NME was the defeat of all departments of the barrel. The latent period III peak was within normal limits. The risk of TKR - average. In the preoperative period held conservative vascular therapy and treatment with low molecular weight heparins. Operations developed TKR. In the postoperative period, the state remained heavy, were treated in intensive care and neurosurgical Department.

The patient was discharged to continue conservative treatment by place of residence.

Example 3

Patient X. 47 years. The diagnosis of vestibular Sanoma left. According to NME defeat departments of the trunk was missing. The latent period III peak was within normal limits. The risk of TKR - low. TKR operations was not. The patient was discharged in good condition.

The way bystrowiana, non-invasive, easily tolerated, accurately reflects the state of the brain stem and allows you to pick up adequate therapy in the preoperative period. Because this category of patients is necessary for health reasons, knowledge of the probability of development of trigemino-cardiac reflex in patients with vestibular what Swannanoa operations is an important part of the preoperative examination.

The method of determining the risk of development of intraoperative trigemino-cardiac reflex in patients with vestibular Swannanoa, including the conduct of clinical and diagnostic research, characterized in that it further conduct electrophysiological studies, with acoustic stem brainstem measure the latent period III peak on the curve evoked potentials, and nerve-muscle electric diagnostics detect lesions of the brain stem, and when the indicator latent period III peak above or below normal and lesion of the medial division of the brain stem through the entire thickness of the trunk, or the total defeat of the lateral and caudal divisions of the trunk, or the defeat of all of these divisions are diagnosed with a high degree the risk of intraoperative trigemino-cardiac reflex in patients with vestibular Swannanoa; when the indicator latent period III peak above or below normal and the absence of lesions of the brain stem, or if the indicator latent period III the maximum norm and the defeat of the medial division of the brain stem, the whole thickness and the total defeat of the lateral and caudal divisions of the trunk at the same time, or the loss of the medial segments of the stem diagnose average risk; when the normal is the service provider latent period III peak and the absence of lesions of the trunk diagnosed with low risk.



 

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