Method for treatment of ischemic insult in critical severe period

FIELD: medicine, neurology.

SUBSTANCE: method involves carrying out the standard vascular and nootropic therapy. Diazepam is administrated under EEG control with the infusion rate that is calculated by the following formula: y = 0.0015x - 0.025 wherein y is the rate of diazepam administration, mg/h; x is an average EEG amplitude, mcV. Method provides enhancing the effectiveness of treatment of patients. Invention can be used for treatment of patients in critical severe period of ischemic insult.

EFFECT: enhanced effectiveness of treatment.

2 tbl, 1 dwg, 1 ex

 

The invention relates to medicine, namely, neurology, and can be used in the treatment of patients in the acute period of ischemic stroke (AI).

The problem of acute disorders of cerebral circulation is one of the main problems of modern neurology. According to BS Vilensky [2]in the larger cities of the Russian Federation, the annual incidence of stroke up to 2.5-3 per 1000 of the population. This indicator is one of the highest in the world (VDDCORE et al., 2000). In recent years there is a tendency for the rejuvenation of the stroke. People younger than 45 years range from 5 to 15.8% of patients with cerebral vascular accident (Emmortal, 1986; Waserman et al., 1986). Among all acute disorders of cerebral circulation ischemic stroke occurs in 79-82% of cases (BS Vilensky, 1995). According to Cppro et al. [6], the incidence of ischemic stroke in Russia, almost all age groups, 1.5-4 times higher than in other European countries, USA, Australia. Mortality in the group of patients with this disease is high: 8% to 30% (J. Bogousslavsky, 1999). The economic damage caused by strokes, huge. Only on medical care of patients with stroke in the industrialized world consumes up to 4-6% of funds in health systems (G.R. De Frites et al., 2001; P.A.Isard et al., 1992; C-Argentine et al., 2000). Of particular interest is the OST the first period of ischemic stroke, i.e. the first 5 days from the moment of development of the disease (Eyisi et al., 1997).

Neuroprotection is a key direction in the treatment of ischemic stroke in its acute phase. Used for this purpose is the multitude of methods of drug and non-drug therapy, the aim of which is to protect nerve cells from the action of damaging factors. The principal possibility of medication to reduce the damaged brain of oxygen and, consequently, increase the resistance of neurons to hypoxia is discussed since the mid 80-ies. In particular, Limpopo [8] recommended to use barbiturates. Bscience [1] indicates that the application of this group of drugs leads to the binding of free radicals, formed during anaerobic glycolysis, reduced lactic acidosis, as well as to normalize the function of the membranes of nerve cells. Recommended etamine-sodium, phenobarbital, and thiopental sodium. You can also use sodium oxybutyrate.

The possibility of a preliminary analysis of EEG parameters when using barbiturates expressed in Eueropean [5]which can be considered the prototype of the present study. Method was applied to test the sensitivity to barbiturates, based on the data of compr sterowanego spectral EEG analysis.

However, the use of this group of drugs is not safe. So, barbiturates depress consciousness, breathing, lower blood pressure and increase blood viscosity (Bscience, 1986). All this is highly undesirable in the acute period of ischemic stroke. In addition, barbiturates very difficult to dose.

The use of benzodiazepines (diazepam) is more preferred because of their better tolerability smaller effect on the respiratory center. To control for the dose of an administered drug can be used for performance monitoring of bioelectric activity of the brain (BAM) with the subsequent calculation of the rate of administration of diazepam. We use the term managed neurovegetative cerebroprotective (UNVTS).

The novelty of the invention is the use of monitoring the amplitude characteristics of the EEG for the purpose of calculation of the rate of infusion of diazepam.

The essential difference is that the rate of administration of diazepam is calculated by the formula:

Y=0,00125X -0,025, where

Y - speed injection of diazepam (mg/kg/h); X is the average amplitude of the EEG (V).

A graphical depiction of the patterns shown in the drawing.

To simplify the calculation of the rate of infusion of diazepam we have developed a computer program. The original values in the program are on azatel the average amplitude of the EEG in V and body weight of the patient, and the desired value of the speed infusion of diazepam.

In our opinion, the introduction of the drug should support bioelectric brain activity within 25-45 V. The introduction of diazepam on the above estimated model will lead to the fact that the average amplitude of the EEG will not go beyond this interval.

Method execution

To implement UNVC we used the apparatus neuro-cardiac monitoring centaur 11 PC. Used bitemporal imposition of electrodes. The system allows you to monitor the average amplitude of the EEG. Indicators must be removed every 20 minutes. Next, using the above formula or a computer program calculated the rate of infusion of diazepam.

Example

Patient W., 56 years. Diagnosis: acute violation of cerebral circulation in ischemic type in the pool of the left middle cerebral artery. When entering the consciousness clear, oriented in time, place and self, we are not upset, pastwienie not limited to, Central paresis of the right facial nerve, right-sided hemiparesis (right arm and leg raises with reduced power, paresis of the hand and foot on the right), meningeal signs. The total scores for the Scandinavian scale score of 43. The diagnosis is confirmed with computed tomography (CT) of the brain. From the 4th hour the disease was applied UNWC. Every 20 minutes were recorded, the average amplitude of the EEG. Calculation of the rate of infusion was carried out according to the formula above. Only 11 hours was introduced 30 mg diazepam with an average speed of 0.05-0.08 mg/kg p.m. Except UNWC, the patient received standard cardiovascular and neuroprotective therapy. To the third day of the stroke, the patient's condition has improved: increased range of motion in the distal right leg. The total scores for the Scandinavian scale for this period was 48 points.

Results

The study included 50 cases of ischemic stroke in its acute period. Of these, 30 patients with UNWC and 20 patients of the control group. Character stroke verified by CT brain and lumbar puncture. The study included only those cases of ischemic stroke, when the state of consciousness at the time of initial examination was more than 4 points on a Nordic scale. Holding UNVC a more profound violations of clarity of consciousness consider unsafe because of the risk of complications.

Patients received a standard set of drugs:

piracetam, xantina, osmodiuretiki - parenteral, aspirin, Cinnarizine - per os.

To assess the effectiveness of therapy was used in the measurement of the difference of severity of stroke as measured by the Scandinavian scale on the third and the first day of the stroke.

Control the ing group was 20 cases of ischemic stroke, receiving diazepam 10 mg twice daily without monitoring BAM

Start applying UNVC varied from 2 to 22 hours from the development of ischemic stroke. Duration of use UNVC varied from 8 to 22 hours. On average 13,03 hours. The rate of administration of diazepam was from 0,018 up to 0.1 mg/kg/h

When comparing the changes in the difference of gravity of the Scandinavian stroke scale on the third and the first day of the disease in the group UNWC and the control group was received the following information (table 1).

The dynamic indicators of severity of ischemic stroke

Table 1
The dynamics of the severity of strokeThe absolute value (UNVTS)% of total number of patients (UNVTS)The absolute value of (control)% of total number of patients (control)
Improvement2273,331050
Unchanged310630
Deterioration413,33315
Deaths13,3315

Improvement occurred in 22 cases group UNVC that extending t is 73,33%. In the control group the improvement was only in half of the cases. A significant improvement (more than 100% from baseline) were not significantly different in UNWC and control groups. The lack of dynamics for three days of stroke occurred in 10% of cases of group UNVC against 30% of cases of the control group. The deterioration was registered in 13,33% of cases AI group UNVC compared to 15% of cases in the control group. Deterioration of more than 50% from baseline is also often occurred in the control group. In a three-day period AI died, one patient group UNWC. In the control group also had one case of fatal outcome, have occurred on the 11th day of the disease, i.e. outside the study time period.

The average score of the dynamics of the severity of patients AI for the first three days of the disease was 5.9 for group UNVC against 2.4 points for the control group (p=0.05). However, in cases where the treatment of patients UNVC group started earlier than 12 hours from the development of AI, the average dynamics was 6.22 points. In the group of patients when treatment was started later than 12 hours from the disease, the average dynamics was 5.0.

The dynamics of various neurological syndromes of ischemic stroke

That the face 2
 ConsciousnessItLocomotor activity handsLocomotor activity legsPastwienie
Improvement (UNVTS)16,67%20%40%43,33%10%
Improvement (Control)5%20%30%15%15%
The lack of dynamics (UNVTS)73,33%73,35%50%50%83,33%
The lack of dynamics (Control)85%75%50%65%85%
Deterioration (UNVTS)10%6,67%10%6,67%6,67%
Deterioration (Control)10%5%20%20%0%

It should be noted that when conducting UNVC more often than in the control group had improved clarity of consciousness, and increased motor activity of the legs (table 2.).

Thus, UNWC is an effective method of treatment of AI in the first days of the disease. The effectiveness is confirmed by significantly the best indicators of the dynamics of the severity of patients for three days Zab the diseases in comparison with the group of patients treated with standard regimens.

Literature.

1. Vilensky BS the state of Emergency in nevropatologii: (Manual for doctors). - L.: Medicine, 1986. - 304 S.

2. Vilensky BS Stroke. - SPb.: Medinformatix. - 1995. - 287 S.

3. Tusev H., V.I. Skvortsova, Chechneva NS, Zhuravleva EJ, E.V. Yakovlev Treatment of acute cerebral stroke. - M., 1997. - C.5.

4. De Fritas BORN; Boguslavsky, J. Primary prevention of stroke, Journal of neurology, psychiatry them. Saw. - 2001. No. 1. - P.7.

5. Erokhin O.Y Testing sensitivity to barbiturates in acute stroke: data compressed spectral EEG analysis by fast Fourier transformation. - In the book: XVII Danube Symposium for neurological diseases: Abstracts. M., 1984, vol. 2, p.45-47.

6. Stroke: a Practical guide for the management of patients / Cppro, Mcennis, Juan Gein and others; Per. s angl. A.V. Borisov and others; Ed. by Sam and Wasgomuwa. - SPb.: Polytechnic, 1998. - 629 S.

7. Neretin VA Rehabilitation of patients with cerebrocortical violations // M.: Medicine, - 1986. - c.7-26.

8. Popova L. Neurotraumatology. - M.: Medicine, 1983. - 250 S.

9. Troshin E, Gustov AV, Troshin Overtree violations of cerebral circulation: a Manual, 2nd ed., revised and enlarged extra - Nizhny Novgorod: Publishing house of the Nizhny Novgorod state medical Academy, 2000. - 440 S.

10. Agentine C., Prencipe M. The burden of stroke: a need for prevention, In: Prevention of lschemic Stroke. Eds. C. Fieschi, M. Fisher. London: Martin Dunitz 2000; 1-5.

11. Bogousslavsky J. On behalf of the European Stroke Iniciative. Stroke Prevention by the practitioner/ Cerebrovasc Dis 1999; 9: Suppi 4:1 - 68.

12. Isard P.A., J.F. Forbes The cost of stroke to the NHS in Scotland // Cerebrovasc. Die. - 1992. - 2. P. - 47-50.

The method of treatment of ischemic stroke in the acute phase, including standard cardiovascular and neuroprotective therapy and the introduction of neuroprotective agents under the control of electroencephalography (EEG), characterized in that under the control of the EEG inject diazepam, infusion rate which is calculated by the formula

Y=0,H is 0.025,

where Y is the rate of administration of diazepam mg/kg / h

X - the average amplitude of the EEG in MK V.



 

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