RU2195980C2 - Method for treating the cases of cerebral coma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying remote action of continuous laser radiation in red bandwidth to four areas of patient body surface, each of them having area equal to 20-80 cm². Exposure of cervical, superior thoracic, middle thoracic, inferior thoracic, superior lumbar and lumbosacral segment of the vertebral column and palmary surface of both feet is alternated every other day. Laser radiation beam of 1.5-3 mm diameter and 5-10 mW power scans during 30 s to 3 min each surface drawing Lissajous figure trajectories. Treatment course is 5-10 procedures long under electroencephalogram control. EFFECT: enhanced effectiveness of treatment.

Description

 The invention relates to medicine, namely neurosurgery, resuscitation, physiotherapy, and can be used to treat patients, adults and children with impaired consciousness to the level of coma I-II degree, stupor, stunning due to severe injuries to the skull and brain, acute brain disorders blood circulation, after operations on the brain (removal of hematomas, vascular malformations, tumors, clipping aneurysms, etc.).

 Known for the medical treatment of cerebral coma by intravenous administration of Nootropil (Mashkovsky M. D. Medicines. T. 1. Minsk, 1987. - S. 101-103). However, the method does not provide optimal restoration of brain function, since, improving metabolism, does not restore the bioelectric activity of the brain, it has side effects.

 The prototype of the proposed method is a method for treating cerebral coma by intravascular laser irradiation of blood through a fiber with a diameter of 349 μm by a helium-neon laser with a wavelength of 0.63 μm and a power of 2-2.5 mW with an exposure of 60 min in 1-10 days of the acute period in patients with severe cranial -brain injury and loss of consciousness to a coma of the I-II degree, stupor, stunning. The method allows to reduce cerebral circulatory hypoxia (Germanovich V.V. Laser blood irradiation in the acute period of severe traumatic brain injury. Author's abstract. Diss ... Ph.D. Medical Sciences. St. Petersburg, 1997, 18 pp.).

 However, the known method is invasive and can cause complications (infection, thrombosis, etc.). The method does not provide optimal restoration of brain function, which is carried out indirectly through photobioactivation of the blood and a decrease in hypoxia. At the same time, there is no purposeful stimulation of the regeneration of brain structures and restoration of the bioelectric activity of the brain. The method is proposed for the treatment of only adult patients.

 The invention is aimed at creating a non-invasive method for treating cerebral coma, providing optimal restoration of brain function and its bioelectric activity in the treatment of patients of different age groups.

The essence of the invention lies in the remote percutaneous exposure to continuous laser radiation of the red spectrum. Irradiate 4 body surfaces with an area of 20-80 cm ² . Irradiation of the cervical-upper chest, middle chest, lower chest, upper lumbar and lumbosacral spine and radiation of the palmar surfaces of both hands and plantar surfaces of both feet alternate every other day. A laser beam with a diameter of 1.5-3 mm with a power of 5-10 mW scans with a frequency of 200 Hz along the trajectories of the Lissajous figure for 30 s - 3 min on each surface. The course of treatment consists of 5-10 daily procedures and is carried out under EEG control.

The inventive method differs from the prototype in that they act remotely on 4 body surfaces with an area of 20-80 cm ² , alternating every other day with irradiation of the cervical-upper chest, middle chest, lower thoracic-upper lumbar and lumbosacral spine and irradiation of the palmar surfaces of both hands and plantar surfaces of both feet, in this case they are exposed to a scanning beam with a frequency of 200 Hz along the trajectories of the Lissajous figure with a laser beam with a diameter of 1.5-3 mm with a power of 5-10 mW for 30 s - 3 min. on each surface with a course of 5-10 procedures under EEG control.

 Irradiation of the projection of the spinal cord throughout the spinal canal contributes to the activation of metabolic processes in all its structures, including cerebrospinal fluid (cerebrospinal fluid) as the most mobile structure due to biological capabilities. The activation of the components of cerebrospinal fluid occurs. The activated substrates of cerebrospinal fluid washing the brain along the cerebrospinal fluid pathways affect both the median structures of the brain from the sylvian aqueduct and the ventricles of the brain, and the convex and basal surfaces of the cerebral cortex from the side of subarachnoid spaces and cisterns of the brain.

 In this case, the projections of the sympathetic chain and structures that carry out autonomic innervation are irradiated: at the thoracic level - of the heart and lungs; thoraco-lumbar level of the digestive tract, lumbosacral level - the urinary system. This helps to activate the functioning of organs and life support systems, harmonious mobilization of biological reserves of survival.

 When the palms and soles are irradiated, receptors and terminals of nerve fibers are exposed. In this case, the activation of axoplasm and other components of axons (membranes, substances, Schwann membrane) occurs. As part of the most important neural axonal pathways of the median, ulnar and sciatic nerves, the activated components of the axons act on the neurons themselves, the conjugated structures of the spinal cord and the reticular formation of the brain stem, which are already in a state of increased activity after the first procedure.

 There is a double stimulation of the entire nervous system, the leading links of which are cerebrospinal fluid and axoplasm of the nerve conductors. In addition, during both procedures, blood vessels and red blood cells are exposed to radiation, which helps to reduce hypoxia throughout the body.

The method is as follows. Treatment is performed for a patient with impaired consciousness to the degree I-II coma ("reactive coma"), stupor or stunning due to traumatic, vascular or tumor damage to the brain, after neurosurgical interventions. Assessment of the level of consciousness on the Glasgow scale is not less than 5-6 points (Konovalov A.N., Likhterman L.B., Potapov A.A. Classification of craniocerebral injury. Collection of scientific works. M., 1992, p. 44 ) In a state of cerebral coma, the clinical signs of focal brain damage are not clear. Treatment is started under condition of stabilization of life support functions, restoration of independent breathing, absence of purulent complications, i.e. subject to compensation systems:
- respiratory (permissible periodic connection to the ventilator);
- cardiovascular (stable within the permissible fluctuations of the pulse and blood pressure);
- digestive (type of nutrition - probe, independent or mixed, the presence of daily bowel movement);
- urinary (excretion of urine through a catheter, lack of signs of damage to the renal parenchyma).

 These signs serve as clinical indications for low-energy scanning laser therapy.

The state of the functioning of the brain and the presence of central nervous system reserves are judged on the basis of an EEG examination conducted immediately before treatment. At the same time, general and local changes in the spontaneous bioelectric activity of the brain are evaluated with a quantitative analysis of the spectral power of the biopotentials in the ranges of delta, theta, alpha and beta rhythms. Brain reactivity is investigated using photo- and phonostimulation. The basis for the proposed treatment is the presence in the patient of an electrographic abnormal pattern typical of a coma of the I-II degree ("reactive coma") and including the following markers:
- disorganization or complete absence of the main (alpha) rhythm;
- dominant activity - diffuse polymorphic slow waves of the delta theta range of various amplitudes;
- interhemispheric asymmetries and focal changes in biopotentials due to the presence of foci of brain damage;
- the variability and reactivity of the EEG pattern to external stimuli - light, sound ("reactive coma").

 These signs serve as electrographic indications for low-energy scanning laser therapy.

 Data on the compensated state of organs and systems indicate the presence and possibility of mobilizing reserves for regenerative and reparative processes in the central nervous system. The proposed method of treatment relates to restorative physiotherapy, and its effectiveness largely depends on the availability of reserves in the nervous system and other systems of the patient's body.

They act by remotely continuous laser radiation from a semiconductor laser with a wavelength of 0.67 microns or a helium-neon laser with a wavelength of 0.632 microns. A laser beam with a diameter of 1.5-3 mm and a power of 5-10 mW with a radiation flux density of 143-565 mW / cm ² scans with a frequency of 200 Hz a Lissajous figure adapted in shape and size (frame 9 "grid") onto the irradiated surface of the patient's body. The distance from the cut of the scanning device to the irradiated surface is 1 m.

In one procedure, 4 fields are irradiated with an area of 20-80 cm ² . The duration of exposure on one field is 30 s - 3 minutes with a duration of the entire procedure 2-12 minutes. The course of treatment consists of 5-10 daily procedures. The dose of one procedure and the course dose correlate with the age of the patient and his condition (table).

The fields of influence are:
- in the first procedure - cervical, middle thoracic, lower thoracic - upper lumbar and lumbosacral spine, i.e. vertebral and paravertebral surface throughout;
- in the second procedure - the palmar surfaces of the hands and the plantar surfaces of the feet.

 Subsequently, the effects on the spine and limbs alternate every other day.

 Clinical criteria for the effectiveness of the performed treatment are signs of restoration of impaired consciousness, a decrease in the degree of cerebral coma and / or its relief, when the level of consciousness on the Glasgow scale is estimated at 7-15 points. Against this background, focal symptoms of brain damage corresponding to the morphological substrate of the lesion can clearly manifest themselves.

 The electrographic criteria for the effectiveness of the treatment performed are the disappearance from the recording of pathological forms of activity, the appearance of elements, and then the regular main (alpha) rhythm, which has high diagnostic significance in relation to a positive prognosis.

 A second course of treatment is carried out no earlier than 2-3 weeks later.

 The method is developed in the Russian National Research Institute of Chemical Technology. prof. A.L. Polenova and passed clinical trials in the treatment of 6 patients with cerebral coma due to severe traumatic (3), vascular (2) and tumor (1) brain lesions. The treatment was carried out in the postoperative period. Positive dynamics was noted in the form of recovery of consciousness, reduction of neurological deficit, correlating with EEG - rearrangements.

 We give an example - an extract from the medical history.

 Patient N., 16 years old, medical history 48-96, was admitted to the institute on 01/08/1996 with a diagnosis of Closed craniocerebral trauma, severe brain contusion with a primary lesion of basal stem formations, subarachnoid hemorrhage, edema and dislocation of the brain from 06.01 .96. Condition after decompressive trepanation of the skull in the left frontotoparietal-temporal region, overlay of the search milling hole in the right temporal region from 01/06/96. Brain Coma II.

 The road injury was from 01/06/96, operated at the city hospital 28. Upon admission to the institute, the patient was in a difficult condition, self-inadequate breathing, through the endotracheal tube 22 minutes per minute, VIVL, blood pressure 100/70, pulse 84 minutes per minute were performed. There was no contact with the patient, the pupils were narrow without reaction to light, corneal reflexes were lethargic, reacted to pain stimuli with extensor cramps, tendon reflexes were low, on the verge of loss, pathological stop signs, meningeal syndrome. 01/08/96 ventricular drainage was applied according to Arendt through the front horn of the right lateral ventricle. Received intensive infusion drug therapy. Over the course of 2 weeks, there has been a positive dynamics in the form of the appearance of a pupil’s reaction to light, an increase in muscle tone - flexors of the arms and extensors of the legs, revitalization of tendon reflexes, and reduction of cerebral edema with signs of atrophy of the brain stem according to computed tomography. Consciousness at the level of coma I-II, on a Glasgow scale of 5 points.

 On the EEG of January 15, 1996, the main rhythm was practically absent, diffuse high-amplitude delta activity in combination with individual theta oscillations dominated in all parts of the brain, the response to light was preserved (Fig. 1). The EEG pattern reflected gross involvement in the pathological process of the brain stem at the ponto-mesencephalic level.

 Further convincing positive dynamics were not observed. Intraarterial administration of vasoactive drugs was performed, percutaneous electrical stimulation of the cerebral cortex at the level of a bone defect, followed by an increase in muscle tone in the limbs, hematuria (possibly in response to a spasm of the muscles of the bladder with a catheter in it), increased sweating, increased blood pressure and tachycardia, continued need for periodic mechanical ventilation.

 On the EEG from January 28, 1996, compared with the previous data, negative dynamics were noted: an increase in the period of slow oscillations, a decrease in amplitude and a significant depletion of rhythm up to "flattened EEGs" in the central leads, the emphasis of changes in the temporal region on the left (Fig. 2). The EEG pattern reflected an increase in stem dysfunction.

 On January 31, 1996, therapeutic anesthesia was performed twice, after which a slight decrease in muscle tone was noted. 02/05/96 marked stabilization of state by vital functions. 02/05/96 a consultation of doctors regarded the patient's condition as a vegetative state with the presence of diencephalic crises. Transferred to supportive symptomatic drug therapy. There were no signs of decompensation of the respiratory, cardiovascular, digestive (tube feeding, regular stool), urinary (hemorrhagic cystitis) systems.

4 weeks after the injury, against the background of the transition from coma I-II to the vegetative state, from 05.02 to 02.20.96, a course of low-energy scanning laser therapy of 5 daily procedures was performed according to the proposed method. The treatment was carried out in the ward using a portable semiconductor laser unit. Influenced remotely by continuous laser radiation. A laser beam with a wavelength of 0.67 μm and a power of 10 mW with a diameter of 1.5 mm with a frequency of 200 Hz scanned a Lissajous figure of 80 cm ² in the cervical-upper chest, mid-thoracic, lower thoracic-upper lumbar, lumbosacral spine - in the first procedure and palmar surfaces of both hands, plantar surfaces of both feet - in the second procedure. In each procedure, 4 fields of 2 min each were irradiated.

 Clinically, from March 6, 1996, the first signs of exiting the vegetative state were noted in the form of eye tracking of a moving object. In the future, positive dynamics in neurological status continued. 03/13/96 marked a turn of the head to a loud sound. Glasgow consciousness rating 7 points.

 On the EEG from 02.28.96 positive dynamics was observed: the number of slow oscillations decreased, some elements of the alpha rhythm appeared, focal changes in the temporal part of the left hemisphere persisted (Fig. 3).

 The course of treatment was discontinued due to exacerbation of hemorrhagic cystitis, which was stopped within a month.

 From 03/18/96, 2 months after the injury and 4 weeks after the first course of scanning laser therapy of 5 procedures, a second course of scanning laser therapy of 10 daily procedures was carried out according to the proposed method. A helium-neon laser system was used (wavelength 0.632 μm, beam diameter 3 mm). The treatment was carried out in a laser cabinet.

 After the first 2 procedures, the patient began to carry out simple commands. After 5 procedures, a consultation of doctors dated 03.23.96 noted a progressive improvement in the general and neurological condition of the patient. Glasgow score 10 points.

 The course of treatment is completed 03/29/96. When examining a patient 04/01/96 consciousness is clear (15 points on the Glasgow scale). There was a distinct focal neurological symptomatology, which coincided with the morphological substrate (the zone of damage to the basal parts of the brain): dysarthria, bulbar paresis, tetraparesis, impaired function of the pelvic organs.

 On the control EEG from 04/01/96, performed at the end of the course of treatment, further positive dynamics was noted with the formation of the main rhythm, focal changes in the temporal part of the left hemisphere are weakly expressed (Fig. 4).

 Over the next month, exercise therapy was carried out with an active expansion of the regimen, massage, speech therapy sessions, electrical stimulation of paretic muscles. From 04.17.96 suffered a relapse of hemorrhagic cystitis. Verticalization was performed at the end of April 1996 after stopping cystitis. During May, speech improved significantly, and began to walk independently. Discharged in satisfactory condition on 05/21/96.

 On the EEG from 05.21.96, the main (alpha) rhythm is regular, focal changes are almost smoothed out (Fig. 5).

 Thus, in a patient with cerebral coma I-II due to severe traumatic brain injury after intensive infusion drug therapy, therapeutic anesthesia and electrical stimulation of the brain for a month, the state of chronic cerebral coma (vegetative status) was ascertained, which was confirmed by EEG indices. Treatment according to the proposed method allowed to bring the patient out of the state of cerebral coma, to carry out rehabilitation treatment according to focal neurological symptoms. At the same time, EEG control established signs of restoration of the bioelectric activity of the brain.

 Using the proposed method eliminates invasiveness, provides optimal restoration of brain function and its bioelectric activity in the treatment of patients of different age groups with impaired consciousness to coma I-II degree due to severe brain damage.

Claims (2)

1. A method of treating cerebral coma, including exposure to continuous laser irradiation of the red spectrum, characterized in that the irradiation is carried out remotely by scanning at a frequency of 200 Hz along the trajectories of the Lissajous figure with a laser beam with a diameter of 1.5-3 mm with a power of 5-10 mW, while 4 body surfaces with an area of 20-80 cm ² for 30 s - 3 min on each surface, irradiating the cervical-upper thoracic, middle thoracic, lower thoracic-upper lumbar and lumbosacral spine in the first procedure, in the second palm procedure surfaces of both hands and plantar surfaces of both feet, procedures alternate every other day, for a course of 5-10 procedures.  2. The method according to p. 1, characterized in that the treatment is carried out under EEG control.

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