RU2301630C1 - Method for treating brain ischemia cases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves ligating one or two extracranial branches of the carotid artery within the surgical intervention framework. Superficial temporal artery segment is selected as the extracranial branch and temporal artery trunks are ligated uni- or bilaterally. Ligation is carried out by applying bipolar or monopolar coagulation.

EFFECT: reduced risk of traumatic complications.

3 cl

Description

The present invention relates to medicine, neurology, pediatric neurology, pediatric neurosurgery, adult neurosurgery, and more specifically relates to a method for treating cerebral blood flow insufficiency (deficiency).

To date, the world has developed many ways to improve the blood supply to the brain during its ischemia (Jasargil MG, 1966; Lavrentiev A.V., 2001).

The most common way to create the so-called. extra / intracranial anastomosis (EIKMA) between one of the branches of the superficial temporal artery and the cortical arterial vessel (Dobzhansky N.V., 1994, Vereshchagin N.V., 1996).

Atherosclerosis of the main common, internal carotid artery, as well as the middle cerebral artery with clinical, CT-MRI and angiographic signs of stenosis are the main indications for the creation of such anastomosis mainly on the principle of "end-to-side" (end of the superficial temporal artery to the side of the cortical arterial vessel). In the specialized literature, there was a big discussion about the effectiveness of these surgical interventions and so far this issue cannot be recognized as finally resolved. The main reason for the ineffectiveness of these surgical interventions is thrombosis of the site of the anastomosis, which cannot be eliminated in any way.

Another well-known method for treating cerebral ischemia is the creation of the so-called encephaloduroarteriosinangiosis in the disease / my-mine syndrome (indirect anastomosis between one / two branches of the superficial temporal artery and the surface of the brain). Efficiency here is believed to be achieved by gradually organizing the microvascular network on the surface of the brain and, thus, improving (strengthening) the blood supply to the brain bypassing the stenotic area (Matsushima T, 1994).

All of the above methods of combating cerebral ischemia are associated with a complex diagnostic complex, including unsafe invasive studies of cerebral blood flow (for example, CAG - carotid angiography), as well as technical difficulties in the neurosurgical execution of EICMA, including the need for trepanation (even if it is small , minimal), prolonged anesthetic management and some other problems. In addition, for example, in children it is difficult to distinguish the branches of the superficial temporal artery, which is special in younger age groups, and thus, the creation of EICMA is impossible in principle.

The present invention was the creation of a new method for the treatment of cerebral ischemia, which would be devoid of the above disadvantages, would be relatively simple, less traumatic, would not require serious anesthetic support and, at the same time, would be effective for the treatment of chronic cerebral ischemia and with her various neuropsychiatric disorders.

This problem is solved by the fact that in the method of treating cerebral ischemia in which neurosurgical intervention is carried out, according to the invention, at least one extracranial and / or at least one intracranial membrane branch of the carotid artery is ligated during the intervention.

Preferably, the main trunk of at least one superficial temporal artery is ligated. Moreover, in the particular case, they can ligate the main trunks of both superficial temporal temporal arteries.

In another particular case, ligation of the intracranial sheath artery meningea media (a.meningea media) can be performed from at least one of the sides. In this case, ligation of a.meningea media is preferably carried out by bipolar or monopolar coagulation.

The claimed method is based on the effect of increasing the cerebral blood flow (QMS) by the middle cerebral artery (SMA) by 30-50% after the ligation of one, two or more branches (extra / intracranial) of the carotid artery revealed by the authors. The main instrumental method that confirms the elimination of previously existing violations of the cerebral blood flow velocity and the Gosling pulse index (GI) is ultrasound transcranial dopplerography (US-TKD), which determined the elimination of signs of interhemispheric asymmetry of blood flow velocity and the tendency to normalization of IG values. This effect was achieved by redirecting part of the blood flow from the pool of the ligated branch of the carotid artery to the pool of the internal carotid artery, and thereby eliminated the interhemispheric asymmetry of the cerebral blood flow velocity, as a rule, found in patients selected for surgical treatment. Moreover, improvement in the condition of patients was observed, as a rule, in the period from several hours after the intervention to several postoperative days, which, taking into account the significantly simpler and safer technique for implementing the method, indicates its significant advantage compared to previously known analogues.

The claimed method can be carried out as follows.

If it is necessary to ligate one or more extracranial (superficial) branches of the carotid artery, a small linear incision is made at a typical location projection location of the desired superficial artery. Even before the cut, a more accurate branch location can be established using the 4 Mhz ultrasound Doppler probe.

Next, soft tissues are sequentially stupidly separated and the desired branch of the artery, which usually lies next to the vein of the same name, is exposed. Typically, the branch of the artery and vein are differentiated by the presence of pulsation in the first. If necessary, in the case of their distinguishability by eye, Dopplerography is performed from open sections of blood vessels and the question of their differentiation is solved by the nature of the direction of blood flow on the display of the device.

After this, the desired extracranial branch of the artery is ligated by applying silk ligature, after which it is possible, but not necessary, to vein the vein, although the option without dressing the vein of the same name is quite possible.

Depending on the specific clinical situation, neurological, mental and ultrasound-TCD pictures in a patient, this ligation of the extracranial branch of the carotid artery can be carried out on either one or the other side. Moreover, the ligation of the symmetric branch can be performed immediately (simultaneously), or after a certain time interval (for example, after a few days or weeks or more) depending on the initial condition of the patient and the dynamics of his recovery.

It should also be noted that the choice of a particular branch of the artery depends on the nature and degree of neurological and mental deficiency in the patient. Unilateral or bilateral ligation of the main trunk of the superficial temporal temporal artery is the most convenient, technically simple, and at the same time quite effective, although it is obvious that, if necessary, other superficial arteries can be ligated with the same effect and absolutely identical to the method described above.

If necessary, to enhance cerebral blood flow, one or more intracranial membranous branches of the internal carotid artery can be ligated. The simplest from a technical point of view may be single or double-sided ligation a. meningea media. Accordingly, in the classical place of exit of the desired artery to the dura mater through an enlarged trepanation opening, the desired artery (or arteries) is ligated, for example, by bi- / monopolar coagulation.

The following is a series of clinical observations made during the testing of the proposed method of treatment in the clinic "Alexandria", Moscow.

Observation N 1. Patient A., 11 months old, was admitted to the clinic after prolonged outpatient and inpatient treatment in various clinics due to the increasing delay in psychomotor development. First pregnancy, first birth. Pregnancy proceeded without features, was constantly under the supervision of an obstetrician-gynecologist. A girl cannot sit, walk, hold her head, talk (even syllables) on her own. The gaze fixes, monitors the surrounding objects, but does not take toys, does not play with them. Mouth open, tongue sticking out almost all the time. Poor facial expressions, not smiling. Spontaneous movements in the arms and legs are present; there are no data for paresis. The tone in the limbs is diffusely reduced without signs of atrophy. According to the pediatrician, the development of the child corresponds to 2-3 months. In contrast to the actual 11-month. Locally: the large fontanel is practically not determined, overgrown. Previously, the patient was repeatedly performed by ultrasound of the brain through a large fontanel, on which a diffuse atrophic process was revealed, most likely perinatal hypoxic origin (expansion of subarachnoid fissures, interhemispheric fissure, moderate ventriculomegaly).

When ultrasound-TCD of the middle cerebral artery is determined on two sides: on the left is the cerebral blood flow velocity (QMS) of 58-62 cm / sec in the M1-M3 section, the Gosling pulse index is 1.2-1.3; right QMS in the area M1-M3 80-90 cm / sec. Thus, pathologically low blood flow by SMA on the left, pronounced (more than 15%) interhemispheric asymmetry of the QMS is noted. Relatives of the patient were offered neurosurgical treatment - simultaneous sequential ligation (ligation) of the main trunk of the superficial temporal artery from two sides, which was done. The postoperative period was good, the sutures were removed, the primary healing. During the control ultrasound-TCD a few days after the surgical treatment, the QMS values on the SMA are equalized on both sides to 74-79 cm / sec. In parallel with the improvement of ultrasound-TCD, a clear positive neurological dynamics was also noted. The girl holds her head on her own, tries to sit independently without support; the mouth is closed, the tongue sticks out constantly, a richer facial expression appeared, the child began to smile. The follow-up history was traced for one year. Throughout its duration, a decrease in the delay in psychomotor development was noted, the girl began to walk, pronounce syllables, sounds, and became interested in toys.

Observation N 2. Patient S., 6 years old, was admitted to the clinic accompanied by his mother, from the words of which it is known that the child is noticeably behind in mental development, practically does not speak, knows 2-3 words and as many syllables. The mother of the child notes the expressed motor activity of the child, cannot sit in one place for a minute, is not attentive, is not able to do something for a certain time. Speech can be carried out by the team, but at the same time we manage it with great difficulty, many times we have to demand the same thing. It is accessible to elementary contact, but it quickly depletes and loses interest in communication. It was observed and treated by a neurologist at the place of residence, but without noticeable improvement. Neurological status: gross delay in psycho-speech development, severe attention deficit hyperactivity disorder. Paresis was not detected, the functions of the pelvic organs are not impaired, it controls urination and defecation. The boy underwent an MRI of the brain that did not reveal any significant changes: the substance of the brain is of normal density, the ventricular system is of the normal configuration, it is not displaced, it is not deformed, there is a slight expansion of subarachnoid gaps. With ultrasound-TCD, the decrease in QMS by SMA on the right to 55-58 cm / s is determined, on the left the QMS is 64 cm / s, the Gosling index is 1.5 and 1.0, respectively. Thus, dopplerographic signs of QMS and IG deficiency with respect to the age norm, as well as the presence of signs of interhemispheric asymmetry (> 15%) were established. EEG revealed signs of significant inhibition of bioelectric activity in all parts of the brain, a reduced alpha rhythm, periodic epileptiform signs.

Considering the unsuccessfulness of the earlier conservative treatment, the existing deficit of QMS for SMA is more on the right, the patient was offered surgical treatment, to which the parents agreed. Performed simultaneous ligation of the main trunk of the superficial temporal artery on both sides. Healing by primary intention, sutures were removed on the 10th day.

The follow-up history was traced for 8 months, there was a noticeable positive trend in the form of regression of ADHD syndrome to its mild degree, the vocabulary expanded significantly, began to speak, add phrases, became more manageable and obedient. During the control ultrasound-TCD, before the patient’s discharge, the QMS values on the MCA are equalized to 70-73 cm / sec on both sides, the IG was equalized on both sides to values of 1.1. It is recommended that the patient's parents be constantly monitored and treated by a pediatric neurologist, speech therapist, pediatric psychiatrist, and other necessary specialists.

Observation N 3. Patient V., 10 years old, was admitted to the clinic after a preliminary outpatient follow-up examination in the clinic. He entered the clinic for neurosurgical treatment at the request of the parents.

From the anamnesis it is known that he was born from the first pregnancy, proceeding against the background of toxicosis. Delivery on time. During childbirth he suffered a hypoxic state (asphyxiation?). Later it was observed by a pediatric neurologist, there was a gross delay in psycho-motor development, the child developed epileptiform (convulsive) syndrome, asthmatic syndrome. In infancy, he was repeatedly treated inpatiently and on an outpatient basis, and received medical treatment. The effect of anticonvulsants and anti-asthma drugs was. However, drug therapy with metabolic and vitamin preparations did not lead to significant progress in higher cortical functions. Has not received anticonvulsants over the past year. Parents noted a spontaneous cessation of seizures over the past eight months. Before entering the clinic, the child was not examined for a long time by instrumental and clinical methods.

Neurological status: in consciousness, there is no spontaneous speech. He lags sharply in motor and intellectual development: there is no formed speech, he does not serve himself, he is not interested in toys, he does not play either with himself or with adults. The face is symmetrical. Semioptosis on both sides. The gaze does not fix. Vision is probably good - it can take a small object, catches an outstretched hand. The tongue "chews". Practically does not fulfill instructions due to misunderstanding of the task Swallowing is not broken. The voice is loud, pronounces individual sounds and sometimes individual syllables, turning into a cry, sometimes together with stereotypical movements of the body and limbs. Hearing, tentatively, is normal. Tendon reflexes on the hands are enlivened, without a clear difference of sides; from the feet - busy, more to the right. The tone in the legs is increased in spastic type. The feet are deformed, more to the right (contracture). It can walk on its own, but when walking only periodically leans on a full foot, goes “on toes”. Scoliosis is detected. There are no meningeal and pathological signs. Sensory impairment cannot be detected.

Surveys: MRI of the brain in the axial, coronary, sagittal plane in T1 and T2 modes. The median structures are not displaced, the ventricles are not dilated, symmetrical. At the border of the body and the posterior horn of the right lateral ventricle, a section of the increased signal in T2 mode and slightly reduced in T1 mode, 0.5 cm in size, most likely of vascular origin, is detected. In the medio-basal sections of the left temporal lobe, a cyst up to 1.0 × 0.5 cm in size is detected. Cortical grooves are not dilated. The external cerebrospinal space at the level of the frontal lobes is expanded from 0.5 to 0.7 cm. The interhemispheric gap in the anterior sections is expanded. Ophthalmologist consultation: both eyes are normotonic, calm. Front section, optical media - without pathology. There are no focal and stagnant changes in the fundus of both eyes. Ultrasound-TDH: significant changes in the cerebral blood flow velocity along the ICA upon entry into the skull from two sides up to 49-50 cm / sec on each side are noted (low values). SMA is detected by SMA on the M1 site on the left and increased blood flow on the right (90 and 80 cm / sec, respectively) with multidirectional changes in the Gosling pulse index: from 0.48 to 2.28. The blood flow power on the left is better than on the right, no significant interhemispheric asymmetry of the cerebral blood flow velocity was detected. EEG: pronounced diffuse changes in the bioelectrical activity of the brain according to the type of rhythm disorganization at an increased amplitude level. The slow-wave activity of the theta-delta range prevails in all departments, and more - in the left hemisphere of the brain. The main alpha rhythm is not visible on the EEG. Distinct dysfunction of the stem-subcortical structures. Synchronous subcortical-stem paroxysmal signs. With three-dimensional localization of pathological activity, a predominance of slow-wave paroxysms on the right in the temporal sections is noted.

In general, a neurologically ill patient was assessed as having severe consequences of a perinatal hypoxic-ischemic brain injury. Gross delay in psycho-motor and speech development. Epileptiform syndrome. Spastic tetraparesis.

An operation was performed - ligation of the main trunk of the superficial temporal artery from two sides. The operation went without complications. The early postoperative period without features. Primary healing. Subsequent neurological observation showed a positive trend in the form of the cessation of screams with motor stereotypes, decreased tone in the lower extremities (it is better, more confident, walks, can step on the whole foot). In addition, the child’s view became significantly more “focused”, fixed, more “meaningful”, and began to follow basic instructions. He was discharged for further outpatient treatment and observation. The follow-up history was traced for 9 months. When ultrasound-TCD before discharge, as well as in dynamics, there is a tendency to normalize the values of the QMS and IG on the SMA from both sides to typical age indicators,

Observation N 4. Patient O., was admitted to the clinic at the stage of exit from the appal syndrome. About a year ago, under unclear circumstances, he received a severe hypoxic-ischemic brain injury. Inpatiently treated at the place of residence and in other clinics, conservative drug treatment, massage, exercise therapy were carried out. Neurological status: does not fix the gaze for a long time, monitors the events taking place around itself, there is an elementary mimic reaction. The dominant facial expression is a smile. He holds his head poorly, falls forward. Rough spastic tetraplegia, limbs are in a reduced (bent) state. Diffuse muscle atrophy of the muscles of the limbs. Tendon reflexes from the arms and legs are high. Pronounced proboscis reflex. The functions of the pelvic organs are impaired by the type of incontinence, there are attempts to control them. The patient was repeatedly performed CT, MRI of the brain, which revealed the characteristic (typical) signs of a diffuse atrophic process in the brain. Previously, the patient underwent positron emission tomography of the brain (PET), according to which there is evidence of insufficient blood supply to the brain, the presence of ischemic zones in the cerebral cortex mainly in the temporal-parietal regions. When ultrasound-TKD of the brain by SMA from two sides is determined by a decrease in the QMS on the right to 50 cm / s and on the left to 58-60 cm / s, IG values are 1.8-1.5, respectively. Relatives of the patient were offered surgical treatment - ligation of the main trunk of the superficial temporal artery on both sides, to which they gave their consent. The postoperative period was uneventful, healing by first intention, the sutures were removed. In the postoperative period, a distinct positive neurological dynamics was noted, which can be associated with the surgical intervention. Significantly expanded emotional reactions, monitors the conversation, trying grimace, emitted sounds to respond to those present. Some (small) movements in the hands appeared in the form of flexion in the elbow joints. An ultrasound scan of the brain before discharge revealed positive Dopplerographic changes in the form of QMS recovery by SMA on the right to 60-63 cm / sec and on the left to 57-59 cm / sec, the Gosling index. Further therapy, rehabilitation measures are recommended.

Observation N 5. Patient I., 1.5 months. Consulted and treated by us in another medical institution. The girl is on a breathing apparatus, transferred to mechanical ventilation in connection with the developed series of tonic-clonic seizures shortly after childbirth. Received anticonvulsants intravenously, intramuscularly. Thus, the patient received the so-called. therapeutic anesthesia. From the anamnesis, as well as from the words of the parents, it is known that the woman in labor had complications during childbirth, which apparently led to hypoxic-ischemic damage to the fetus. Obstetric history is burdened, toxicosis, the threat of miscarriage, a long anhydrous period, stimulation of labor. By the time of the examination, she has been on mechanical ventilation for two weeks already, receiving the maximum possible dosage of anticonvulsants for her age. However, it was not possible to completely suppress the convulsive syndrome. Neurologically: there are no focal symptoms, the pupils are narrow, the eyeballs are in the middle of the palpebral fissure, photoreactions are present. There are no meningeal signs. With a small interval there are tonic-clonic convulsions.

When US-TCD revealed a significantly reduced blood flow in the MCA on both sides to 55 cm / sec, without hemispheric asymmetry, IG is high 2.2 -2.0. Due to the ineffectiveness of the anticonvulsant therapy, the girl’s relatives were offered surgical treatment - ligation of the main trunk of the superficial temporal artery, which was performed. Primary healing, sutures removed. After a neurosurgical intervention, the convulsive syndrome is almost completely gone, the patient is removed from mechanical ventilation, and small maintenance doses of anticonvulsants are left. The follow-up history was traced for 6 months, somewhat lagging behind in overall development, but the prognosis according to children's neurologists and pediatricians is favorable. There is no convulsive syndrome.

It should be noted that all examples are provided solely to confirm the effectiveness of the claimed method and achieve the claimed result. These examples are not exhaustive, and should in no way be considered as limiting the scope of claims, since, taking into account the foregoing, it will be obvious to a specialist that a similar effect can be achieved with one- / two-sided and / or one- / two-stage ligation other extracranial (supraorbital, suprablock arteries) and / or intracranial sheath branches of the carotid artery (anterior and posterior sheath arteries).

Claims (2)

1. A method of treating cerebral ischemia, including neurosurgical intervention, characterized in that in the process of intervention, one or two extracranial branches of the carotid artery are ligated. 2 The method according to claim 1, characterized in that the ligation of the trunks of the superficial temporal artery is carried out on one or both sides. 3. The method according to claim 1, characterized in that the ligation is carried out by the method of bipolar or monopolar coagulation.