Method for treating the cases of subarachnoid hemorrhages by means of liquor filtration

FIELD: medicine.

SUBSTANCE: method involves clipping aneurysms and setting two catheters into chiasmatic cistern and into internal carotid artery cistern. After having finished the operation, liquor is discharged concurrently from chiasmatic cistern and internal carotid artery cisterns in the amount of 5-7 ml at a rate of 30-40 ml/h. Two F90PvB Portex filters are sequentially attached to each catheter and the collected liquor is introduced at a rate of 30-40 ml/h and filtered. The cycle is repeated until one volume of circulating liquor is filtered. The process is repeated 6 h later in taking one filter off from each catheter and liquor filtration is continued through one filter. The liquor filtration sessions are repeated every other day depending on subarachnoid hemorrhage intensity. Total liquor filtration treatment is not to last more than 96 h long.

EFFECT: enhanced effectiveness of treatment.

3 cl

 

The invention relates to medicine, namely, neurosurgery, and can be used to improve the clinical results of treatment of patients with subarachnoid hemorrhage due to rupture of arterial aneurysms of the cerebral vessels.

Known method of lycoriella with subarachnoid-parenchymal hemorrhages, when after lumbar puncture in the interval L3-L4 puncture needle is attached system sterile disposable filter PALL CSF FILTER" (USA), and then manually or via a bidirectional pump is filtering the liquor volume 5 - 7 ml simultaneously with a speed of 40-50 ml/hour for about 90 minutes is Filtered about 60 to 80 ml of cerebrospinal fluid. If lycoriella trapped particles and protein fractions with molecular weight more than 3 kilodaltons, it allows you to delay tumor necrosis factor, immunoglobulins G,M, interleukins 2,6, cytokines, IFN-γ, factor activation of the complement C5 (Mironov, NV, Bugaev B.C., Mironov, I., Shmyrev VI//Lycoriella in the treatment of certain neurological diseases/Kremlin medicine. Clinical journal.-1988.- No. 3.- July-September).

A significant drawback of this method is the high risk of dislocation of the brain in the great foramen with the development of disorders of vital functions that the result can be fatal. With this method the most effective rehabilitation of spinal fluid occurs in the area of its active fence in the filtration system, i.e. the end of the tank, and when the rupture of arterial aneurysm the blood is mainly localized on the basal surface of the brain, which leads to spasm cisternal segments of arteries carotid and vertebrobasilar pools, causing vasospasm and cerebral ischemia. Authors during the procedure using a single filter, which leads to a fast closing its pores formed elements of blood and inefficiency lycoriella in the future. This method is used in various aetiology of subarachnoid hemorrhage, and the presence deliberandi arterial aneurysm brain caused by vibrations liquor pressure can lead to a re-rupture and death.

Closest to the claimed method is lycoriella after subarachnoid hemorrhages of different etiology (traumatic brain injury, against the background of hypertension, rupture of arterial aneurysm) through a semipermeable membrane (capillary dialyzers small size)that allows for the intake and return of cerebrospinal fluid at the same speed. We used the following outlines extracorporal the Noah of liquorous: brain ventricles - end tank; a large occipital tank - end tank; two level lumbar subarachnoid space, chiasm tank - end tank. Speed lycoriella 4 ml/min, the duration of the procedure from 3 to 8 hours. Catheterization liquor spaces is performed according to the method of the Seldinger PVC catheter with a diameter of 1 mm (Radushkevich V.L., Gorbachev VI // Experimental substantiation of lycoriella after subarachnoid hemorrhage // Bulletin of intensive therapy. - 1993. No. 2-3. - P.29-31; Lopukhin, Y.M., Gorbachev V.I., Petrov, S., Gitelson A.A., Sorokovikov VA, Elizov O.V. // Use lycoriella in the treatment of subarachnoid hemorrhage / Efferent therapy. - 1997. No. 3. - P.21-25).

A significant drawback of this method is the use of extracorporeal circuits liquorous (brain ventricles - end tank; a large occipital tank - end tank; two level subarachnoid space) is a high risk of dislocation of the brain in the great foramen with the development of disorders of vital functions, which ultimately can lead to death. The need for puncture of the lateral ventricles and the large occipital tank is associated with a high risk of additional trauma to the brain and is the development of intracerebral hemorrhage, which leads to the worsening condition of patients, including death. In some cases, because of brain edema is the puncture of the ventricles of the brain is impossible. In this method, there is a need for a control CT scan brain to verify the location of the catheter in the spinal fluid space that requires additional technical difficulties and the cost of treatment. Used methods of catheterization liquor spaces do not provide optimal reorganization of the basal cisterns of the brain, where mainly localized blood at rupture of arterial aneurysm, causing vasospasm and cerebral ischemia. If this method does not take into account the etiology of subarachnoid hemorrhage, the presence of deliberandi arterial aneurysms of the brain may lead to recurrence of the hemorrhage and death. Standard dialysis membranes allow substances with a relative molecular weight of 6000 to 20000 and retain only large protein molecules and cellular elements. Authors during the session lycoriella use one filter, which leads to a fast closing its pores formed elements of blood and ineffective treatments in the future.

The objective of the proposed method is to prevent the starting of the mechanisms of development of the Church is balnogo of angiospasm and secondary ischemic disorders of cerebral circulation, allowing surgical treatment even in conditions of cerebral angiospasm, reduce mortality and improve functional outcomes in patients by rehabilitation of the cerebrospinal fluid after subarachnoid hemorrhage due to rupture of arterial aneurysms of the cerebral vessels.

When the solution is achieved therapeutic effect, a reduction of morbidity and mortality in these patients. He is due both to reduce the likelihood of re-development of hemorrhage and reduce the duration and severity of angiospasm, improving clinical outcomes.

The expected economic effect associated with a reduction in budget expenditures due to the reduction in hospitalization of a patient in this category (according to our forecasts, on average, 7 bed-days), improve treatment outcomes without the use of some expensive drugs and reduce the costs of rehabilitation.

The solution of this problem is achieved by the fact that kopiruyut verified arterial aneurysm, kateteriziruyut epidural minipack 16G (Portex) two basal cisterns (chiasm and the tank internal carotid artery), at the end of the operation, conduct the session lycoriella, including the intake of liquor through the catheter from the chiasm of the tank with a volume of 5-7 ml at speeds of 30-40 ml/h, attached in series two is ultra F90 PvB (Portex) collected and filtered liquor, the liquor is injected at a rate of 30-40 ml/hour; at the same time take away the liquor from the tank of the internal carotid artery in the same volume, put on two consecutive filter F90 PvB (Portex) on the catheter from the tank of the internal carotid artery and perform filtering with the same speed; repeat the cycle for 180 minutes to achieve the filtering of one volume of the circulating liquor, then remove one filter from each of the catheter and after 6 hours refresher session lycoriella through one filter. Sessions lycoriella depending on the intensity of subarachnoid hemorrhage repeat through the day. The total duration of lycoriella should not exceed more than 96 hours.

The technical result is achieved due to the fact that in acute subarachnoid hemorrhage is the clipping of arterial aneurysms, simultaneously catheterization two basal cisterns of the brain (chiasm and the tank internal carotid artery). At the end of the operation are lycoriella through two filters attached to each catheter, while the intake of liquor is conducted from one tank and the refund is equal to the amount previously taken in another tank, which eliminates fluctuations liquor pressure, thus preventing the danger of provoking dislocat the district syndrome brain. Two-stage filtering allows maximum cleaning liquor not only from the formed elements of the blood (through the first filter), but also particles and protein fractions with molecular weight more than 3 kilodaltons (through the second filter). Depending on the intensity of subarachnoid hemorrhage used filters allow multiple sessions lycoriella up to 96 hours. During one session filter about one volume of the circulating liquor. In this way, the most effective reorganization of the liquor in the field of preferential accumulation of blood under arterial aneurysm rupture (cisternal segments of the arteries), which prevents the trigger mechanisms of the development of cerebral angiospasm and secondary ischemic disorders of cerebral blood flow after subarachnoid hemorrhage.

The proposed method is as follows:

Patients with verified subarachnoid cravonline is serial cerebral angiography. After confirmation of the diagnosis, clarify the localization of arterial aneurysms under General anaesthesia craniotomy is performed according to standard methods (often fronto-temporal). Performed microsurgical clipping of the identified arterial aneurysms and thorough sanitation subarachnoid is lnyh spaces from demolizione blood.

After this the installation of two catheters epidural minipack 16G (Portex) in the chiasm and the tank internal carotid artery. The wound is sutured in layers. Upon completion of the operation to each catheter is attached by two filters, not permeable to particles, fungi, bacteria, endotoxins, bacteria F90 PvB (Portex). Manually or by using a bi-directional pump to conduct the session lycoriella, including the intake of liquor through the catheter from the chiasm of the tank with a volume of 5-7 ml at speeds of 30-40 ml/hour. At the same time take away the liquor from the tank of the internal carotid artery in the same size and hold the filter with the same speed. Repeat the cycle for 180 minutes to achieve the filtering of one volume of the circulating liquor (about 90-120 ml of cerebrospinal fluid), and then remove one filter with catheters that delay is mainly formed blood elements.

Repeated sessions of lycoriella carried out after 6 hours through only one filter (retains particles and protein fractions with molecular weight more than 3 kilodaltons) to achieve the filtering effect with respect to the first session of not less than 2 volumes tsirkuliruyuschii of the liquor.

In further lycoriella carry through the day depending on intensity of subarachnoid hemorrhage. The maximum duration of dignity the AI liquor spaces through established catheters in the basal cisterns should not exceed 96 hours.

Clinical example

Patient G in EV, 18 years, is delivered in a neurological hospital ICD No. 1 15.03.03 SMP machine, due to intense headaches, which occurred suddenly on the background of satisfactory health. When entering a serious condition due to the underlying disease. Clear consciousness. AD=160/100 torr.

Neurologically - GCS 15 points, pupils of average size equal to that of expression alive. Of paresis, paralyses no. Tendon reflexes live, S>D. Doskoobraznye stiff neck.

Transferred to the intensive care neurology Department. Performed CT scans of the brain, signs of subarachnoid hemorrhage, in the projection of Silvaloy slit right intracerebral hematoma volume of about 10 ml. When the TCD is determined by the angiospasm in pools of MCA (right - rougher, ISC=182 cm/s).

The patient and relatives categorically refused to undergo cerebral angiography and possible surgical treatment. On a background of conservative therapy, the patient's condition stabilized. Headaches were stopped, were stopped meningeal symptoms.

15.05.03 the patient's condition suddenly deteriorated. The newly developed intensive headaches, with brief loss of consciousness. Despite conducted infusion, antihypertensive, anticonvulsant is arapey the patient's condition is severe, inadequate, disoriented, lethargic, hypertension (BP=180/100 torr), rough meningeal symptoms. Appeared paresis 7 pairs left, left-side hemiparesis (up to 3 points). If TCD is determined by the angiospasm in the pool right MCA (linear velocity in the MCA increased right up to 210 cm/s, left - to 125 cm/s). When lumbar puncture resulting liquor intensively stained with blood (the number of erythrocytes 41120 in ál).

15.05.03 transferred to the Department of microneurosurgery, in an emergency made selective angiography verified arterial aneurysm of the terminal divisions of the right internal carotid artery, the phenomenon of angiospasm, more pronounced in the pool right MCA. For health reasons 15.05.03 performed surgery microsurgical clipping of the neck of the aneurysm of the terminal internal carotid artery on the right of the right pterional approach.

After that, the installation of two catheters epidural minipack 16G (Portex) in the chiasm and the tank internal carotid artery. The wound is sutured in layers. Upon completion of the operation to each catheter was joined by two filters, not permeable to particles, fungi, bacteria, endotoxins, bacteria F90 PvB (Portex). Using bidirectional pump held a session lycoriella, including the intake of liquor through the catheter from the chiasm of the tank volume is m 7 ml at 35 ml/HR. At the same time was taken up the liquor from the tank of the internal carotid artery in the same volume, and the filtration of the liquor at a speed of 35 ml/hour. These cycles are repeated for 180 minutes before reaching the filter 105 ml of cerebrospinal fluid. Then removed one filter with a catheter draining the basal cisterns.

Conducted intensive therapy. The volume of liquid required to compensate for abnormal losses (fever, prolonged artificial ventilation of the lungs), was calculated by known methods.

Was carried out round the clock monitoring of the electrocardiogram, invasive measured intracranial pressure, indicators of systemic hemodynamics (non-invasive monitoring AD), as well as diuresis and laboratory parameters (coagulation, hematocrit, electrolytes and osmolarity of urine).

In the morning 16.05.03 - patient in mind, adequate. At TCD, there is a decrease of blood flow velocity in the MCA to the right (up to 120 cm/s) and of the left MCA (up to 88 cm/s).

After 6 hours after the first session was a repeat session lycoriella at a speed of 30 ml/h for 3 hours, but after one filter. The total volume of filtered liquor was 90 ml

17.05.03 significant regression of focal and meningeal symptoms - increase in the force in the left limbs on 1 point, the decrease in rigidity to 1.5 on reechnyh fingers.

18.05.03 was transferred to the relevant Department. In the future, against the background of rehabilitation therapy has been a marked positive dynamics - complete regression of focal and meningeal symptoms. According to TCD resolution of signs of cerebral vasospasm.

At control angiography (25.05.03) - defined off completely arterial aneurysm of the terminal internal carotid artery on the right, the resolution of angiospasm. 27.05.03 the patient was discharged under the supervision of a neurologist clinic without neurological deficit.

Thus, the application of the developed method lycoriella allowed to quickly sanitize the basal cisterns of the brain, to exclude the development of angiospasm in the postoperative period (this is evidenced by the satisfactory condition of the patient and the absence of neurological symptoms in the postoperative period) and improve clinical outcomes.

1. A method of treating subarachnoid hemorrhage, including catheterization liquor spaces and lycoriella, characterized in that kopiruyut aneurysm and install two catheter chiasm in the tank and in the tank of the internal carotid artery, after finishing operations are carried out by the fence of the liquor at the same time of the chiasm of the tank and the tank internal carotid artery about what yamam from every 5-7 ml at speeds of 30-40 ml/h, then for each catheter attached two consecutive filter F90PvB Portex, enter the withdrawn liquor with a speed of 30-40 ml/h, making it the filter, the cycle is repeated to achieve the filtering of one volume of the circulating liquor; after 6 h, a refresher session, thus remove one filter from each of the catheter and lycoriella passes through one filter.

2. The method according to claim 1, characterized in that the sessions lycoriella depending on the intensity of subarachnoid hemorrhage repeat through the day.

3. The method according to claim 2, characterized in that the total duration of lycoriella should not exceed more than 96 hours



 

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