RU2387371C1 - Method of evaluating vegetative nervous system reactivity in acute period of intracranial hemorrhages - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: inventions relate to field of medicine, namely to neuropathology. Cardiointervalogram is registered at rest, during test and during period of recovery after test. Time analysis of cardiocycles, wave rhythm structure are carried out and complex evaluation of regulatory systems is performed. As test used is lumbar puncture with change of cerebrospinal fluid pressure. In case if intracranial hypertension is absent and contribution of very low frequency waves (VLF) decreases after test, if tense rest vagotonia during puncture transfers into tense balance, and during recovery period into tense vagotonia, tense balance or tension-free balance or if tense rest balance is preserved during puncture and transfers into tension-free balance during recovery period, or if balance at rest transfers into tense vagotonia and into balance during recovery period - VNS reactivity is evaluated as adequate. In case if intracranial hypertension is present or in case of its absence and if VLF is more than 30% after test, if tense rest balance during puncture transfers into tense sympathicotonia, and after that, during recovery period into tense balance or tense sympathicotonia, or if tense rest sympathicotonia transfers into tense sympathicotonia in recovery period with decrease of VLF - VNS reactivity is evaluated as inadequate insufficient. In case of presence of intracranial hypertension, if vagotonia during puncture and during recovery period transfers into tense vagotonia, or sympathicotonia transfers into tense sympathicotonia, or if tense vagotonia and tense sympathicotonia at rest do not change during and after test, or increase of VLF contribution is more than 50% - VNS reactivity is evaluated as inadequate exhausted. ^ EFFECT: method ensures increase of accuracy due to evaluation of impact of supersegmental centres on VNS reactivity. ^ 4 tbl, 6 dwg, 3 ex

Description

The invention relates to the field of medicine, namely neurology, and can be used in patients in the acute period of non-traumatic intracranial hemorrhage (IVCh) to assess the reactivity of the autonomic nervous system (ANS), including patients with severe focal neurological symptoms, varying degrees of violation consciousness and therapeutic anesthesia.

An objective assessment of the functional state of the ANS is an analysis of heart rate variability (HRV).

A known method of assessing the reactivity of the ANS using a breathing test when recording cardiocycles (Babunts I.V., Miridzhanyan E.M., Mashaekh Yu.A. Alphabet of heart rate variability. - Stavropol, 2002. - S.49-50). The results of the test determine the reactivity of the parasympathetic division of the ANS. Two methods of evaluating the results are used - calculating the respiratory coefficient and spectral analysis. Normally, the respiratory coefficient is more than 1.2. A coefficient value of less than 1.2 reflects a decrease in the reactivity of the parasympathetic division of the ANS. When spectral analysis of a breathing test is normal, there is an increase in the power of high frequency waves (HF), and the coefficient of vagosympathetic interaction (LF / HF) is significantly reduced. With a slight decrease in the coefficient LF / HF, or if the coefficient does not change, insufficient reactivity of the parasympathetic division of the ANS is observed. Paradoxical is the reaction in which there is an increase in sympathetic influences.

The disadvantages of the method:

- assessment of the reactivity of the parasympathetic division of the ANS only;

- the inability to use in patients with various degrees of impaired consciousness, gross focal neurological symptoms (for example, with aphasia) and in therapeutic anesthesia.

Closest to the claimed is a method for assessing the reactivity of the ANS using an active orthostatic test (AOP) (Babunts I.V., Miridzhanyan E.M., Mashaekh Yu.A. Alphabet of heart rate variability. - Stavropol, 2002. - P.43- 46), adopted as a prototype.

The test is carried out in three stages after preliminary adaptation to the conditions of the study (rest 10-15 minutes):

1st stage: continuous background recording of the electrocardiogram (ECG) in a horizontal position, breathing is calm;

Stage 2: the patient is asked to stand up, the recording does not stop, and the time intervals between the R-waves of the ECG (RR intervals) are recorded in an upright position, breathing is calm;

3rd stage: after the test, record the cardio intervals in a horizontal position, breathing is calm.

AOP is analyzed based on the nature of the transition process between the first and second stage.

To assess the reactivity of the parasympathetic division of the ANS, a coefficient of 30/15 (K 30/15) is calculated, which is equal to the ratio of the maximum RR interval in the range of 30 seconds to the minimum RR interval in the range of 15 seconds. When the coefficient value is less than 1.35, the reactivity of the parasympathetic division of the ANS is regarded as reduced.

To assess the reactivity of the sympathetic division of the ANS, a spectral analysis of the recording section of the cardiointervalogram in the vertical position is performed after exclusion from the transition period. The criterion of insufficient reactivity of the sympathetic ANS during AOP is considered to be an increase in the relative power of slow waves (LF) at a load compared to the background of less than 10%. The value of the LF / HF coefficient during AOP of more than 16.5 is estimated as excessive reactivity of the sympathetic division of the ANS.

The disadvantages of the prototype:

- insufficiently complete assessment of the reactivity of the ANS, since only the sympathetic and parasympathetic departments of the ANS are evaluated;

- the inability to use in patients in the acute period of NIHC due to the bed rest of the patient, the presence of gross focal neurological symptoms, varying degrees of impaired consciousness and in patients undergoing therapeutic anesthesia.

The invention is aimed at creating a method for assessing the reactivity of the ANS in the acute period of intracranial hemorrhage, which improves accuracy by assessing the effects of suprasegmental centers on the reactivity of the ANS, including in patients on bed rest, with severe cerebral symptoms (varying degrees of impaired consciousness, presence of hypertensive syndrome), gross focal symptoms (aphasia, paresis, ataxia), or in therapeutic anesthesia.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method for evaluating the reactivity of the ANS in the acute period of intracranial hemorrhage, including the analysis of HRV at rest, during the test and during recovery from the test, using a temporary analysis of cardio intervals, variational pulsometry, analysis of the rhythm wave structure and a total assessment of regulatory systems, a feature is that the recording is carried out against a background of lumbar puncture with a measurement of cerebrospinal fluid pressure (CSF); the decrease in tension of higher vegetative centers (NECS), estimated by the contribution of very slow waves (VLF) after lumbar puncture, is regarded as adequate ANS reactivity, thus, with adequate ANS reactivity and the absence of intracranial hypertension, intense background vagotonia during a puncture goes into a tense balance, and when recovering from a sample to a balance without stress, a tense balance with a decrease in the contribution of VLF, or to intense vagotonia; the transition of the tense balance in the background and during the puncture to the balance without tension in the recovery period; the transition of the balance during background recording into intense vagotonia during puncture with subsequent restoration to the balance without NVVC; when the NVVC is maintained or increases during and after the puncture, the ANS reactivity is assessed as inadequate: insufficient or depletion, and with insufficient ANS reactivity, the tense balance at rest goes into tense sympathicotonia during puncture, and then into the tense balance or tense sympathicotonia with a decrease in NVVC in recovery period; intense sympathicotonia at rest turns into intense sympathicotonia with a decrease in NVVC and VLF <50%, and in the presence of intracranial hypertension and depletion of VNS reactivity, intense sympathicotonia or vagotonia with VLF> 50% at rest does not change during and after puncture, or an increase in NVVC occurs.

The method is as follows. An ECG signal is recorded in one of the standard (I, II, III) or chest leads.

1st stage: in a horizontal position with calm breathing, background recording is performed for 5-10 minutes;

2nd stage: in the same position, according to the standard method, a lumbar puncture is performed with CSF excretion and CSF pressure measurement, against which a cardiointervalogram of 5-10 minutes duration is recorded depending on the duration of CSF excretion;

3rd stage: recovery after a puncture lasting 5-10 minutes.

An analysis of several consecutive records of 5 minutes each confirms the conditions for the stability of physiological status.

HRV is evaluated, for which they use methods of temporary analysis of cardio intervals (statistical and geometric), variational pulsometry according to Baevsky P.M., analysis of the rhythm wave structure and methods of complex assessment of regulatory systems.

Analyze:

1. Statistical indicators: SDNN (standard deviation of the values of normal RR intervals); CV (coefficient of variation).

2. Geometric indicators: ΔX - the difference between the values of the maximum and minimum RR interval (indicates the maximum amplitude of the oscillations of the RR intervals); TI (triangular index).

3. Variation pulsometry according to P.M. Baevsky: IN (voltage index of regulatory systems, stress index).

The total spectrum power (TP), absolute values (VLF, LF, HF) in ms ^ 2 and relative (VLF%, LF%, HF% of TP) values of each frequency range are estimated. Calculate: LF / HF; IC (centralization index).

The normative data are the standards for manual and automated HRV analysis adopted by the working group of the European Cardiology Society and the North American Society of Stimulation and Electrophysiology at a joint meeting in 1996, as well as methodological recommendations of the Commission for Clinical Diagnostic Instruments and Apparatuses of the New Medical Committee equipment of the Ministry of Health of Russia (protocol No. 4 of April 11, 2000).

To determine the level of adaptive and adaptive capabilities, an integrated assessment of the state of regulatory systems is carried out according to the SORS indicator (total assessment of regulatory systems), calculated in points using the algorithm (Babunts I.V., Miridzhanyan E.M., Mashaekh Yu.A. Alphabet of cardiac variability rhythm. - Stavropol, 2002. - P.36-37).

Analyze the reactivity of the ANS.

The regulatory effects of higher vegetative centers are assessed by the contribution of VLF to TP. Decrease in NVVC (decrease in VLF) or its complete regression during and after lumbar puncture is assessed as adequate reactivity of the ANS, while maintaining NVVC or its increase, as inadequate reactivity.

According to the degree of change of the NECC, one can distinguish:

1) insignificant NECC - VLF = 30-40%;

2) moderate NVVC - VLF = 40-50%;

3) expressed NVVC - VLF> 50%.

Types of ANS reactivity depending on the degree of NVVC and the presence of intracranial hypertension in the acute period of intracranial hemorrhage are presented in Table 1.

Table 1 ANS reactivity type Degree of NECC (% VLF) Heart rate variability CSF pressure Variant of the course of the disease Background Lumbar puncture Recovery Adequate Complete regression or decrease in stress after the test with a VLF of less than 30% or more than 50% 1. intense vagotonia tense balance - balance without tension; Normotension, or hypertension, followed by regression in the acute period (up to 21 days) 1. Favorable type of flow, compensated condition - intense vagotonia; - tense balance 2. tense balance tense balance balance 3. balance intense vagotonia balance Not enough Slight voltage (VLF = 30-40%) or moderate voltage (VLF = 40-50%) when restored with a decrease in sympathetic effects after the test 1. tense balance intense sympathicotonia - intense sympathicotonia Normotension or hypertension with regression in the acute period II. Unstable course of the disease, subcompensated state - tense balance 2. intense sympathicotonia intense sympathicotonia intense sympathicotonia Exhaustion Severe stress after sample (VLF> 50%) 1. intense sympathicotonia intense sympathicotonia intense sympathicotonia Hypertension III. Adverse course, decompensated condition 2. intense vagotonia intense vagotonia intense vagotonia 3. vagotonia intense vagotonia intense vagotonia 4. sympathicotonia intense sympathicotonia intense sympathicotonia

Against the background of therapeutic anesthesia and the favorable course of the disease with the absence of intracranial hypertension, a rigid rhythm is recorded in patients with SORS from +3 to -3, characteristic of the first two types of ANS reactivity.

Intense sympathicotonia or intense vagotonia with lumbar puncture against a rigid rhythm with SORS from +10 to +12 is a predictor of death in the near term with TP≤10 (ms ² ), and with TP = 1 (ms ² ), one can state brain death, which corresponds to the third type of ANS reactivity - depletion.

The claimed method is developed in the Russian National Research Institute of Chemical Technology. prof. A.L. Polenova and underwent clinical trials in the examination of 12 patients in the acute period of NVChK.

We give examples - extracts from the medical history.

Example 1. Patient N., 28 years old, medical history No. 618, and was admitted to the RNHI on the 3rd day after the first hemorrhage, which developed against the background of physical activity, when during training in the gym there was a sharp pain in the neck and head, after which nausea and vomiting joined against a background of a rise in blood pressure to 140 mm Hg. According to the "Ambulance" hospitalized in a city hospital with a diagnosis of cervical osteochondrosis. CT CT of the brain showed signs of SAH, saccular aneurysm of the paraclinoid division of the right ICA, and therefore was admitted to the RNHI for further examination and treatment. On the 3rd day of hemorrhage, the clinical picture of the disease was represented by cerebral symptoms in the form of a headache of a hypertensive nature, weakly positive meningeal syndrome, reflexes of oral automatism, pyramidal insufficiency from 2 sides, more to the left. Intraoperatively, there was a second CSAA with the formation of a / brain hematoma of the mediobasal parts of the right frontal lobe, signs of vasospasm of the third degree were revealed, and therefore the patient was in medical anesthesia for several days. On the 15th day of the acute period, HRV was analyzed against a background of blood pressure of 127/77 mm Hg, pressure CSF = 180 mm of water. Art. (normotension). The indicators of the heart rhythmogram are given in table.2.

table 2 Peace Lumbar puncture Recovery SDNN (ms) 38.3 58.7 70.3 pNN50 (%) 5.7 7.1 12.2 TI 7.0 14.5 14.7 Heart rate (bpm) 95 90 82 CV (%) 6.07 8.85 9.66 Rrmin (ms) 524 528 568 Rrmax (ms) 776 916 976 X (s) 0.25 0.39 0.41 IN (% / s ^ 2) 217.9 75.7 52.4 Total (ms ^ 2) 637 966 1439 VLF (ms ^ 2) 284 329 429 LF (ms ^ 2) 219 371 674 HF (ms ^ 2) 134 266 335 VLF (%) 45 34 thirty LF (%) 34 38 47 HF (%) 21 28 23 LF / HF 1.64 1.39 2.01 N 475 451 411 IC 4.0 3.0 3.0

Figure 1 presents the rhythmogram at rest, with lumbar puncture and recovery after the sample.

Figure 2 - histograms, tablegrams and power spectra at rest, during and after the sample.

Conclusion: at rest, the patient has a tense balance with a moderate NVVC (40% <VLF <50%, 0.5 <LF / HF <2.5), during lumbar puncture, a tense balance with a decrease in stress (30% <VLF < 40%, 0.5 <LF / HF <2.5), in the recovery period there is a balance with a slight increase in the contribution of sympathetic waves, but without NVVC (VLF = 30%, 0.5 <LF / HF <2.5 at 40 % <LF <50%). SORS = = 4 (state of functional voltage). Adequate ANS reactivity.

After exiting the acute period of hemorrhage, the patient was discharged in a compensated state with mild left-side hemiparesis of up to 4 points and left-side hemigipalgesia without hypertension-hydrocephalic syndrome.

Example 2. Patient Sh., 41 years old, medical history No. 2799, underwent CSA in 2006, upon admission to the institute, the patient underwent repeated SAA of aneurysmal etiology from saccular aneurysm of the paraclinoid department of the right ICA, aneurysm was separated by detachable spirals. When viewed in the first three days from hemorrhage in neurological status, a moderate cerebral symptomatology was observed in the form of a headache of a hypertensive nature, micro-focal symptoms in the form of positive reflexes of oral automatism, pyramidal insufficiency in the form of revitalization of reflexes and the appearance of pathological signs on both sides, more on the left. On the second day of the acute period of the NAO, HRV was recorded before, during and after the lumbar puncture against the background of BP = 100/70 mm Hg, pressure CSF = 200 mm water. Art. (border pressure). The indicators of the heart rhythmogram are presented in table.3.

Table 3 Peace Lumbar puncture Recovery SDNN (ms) 37.0 57.1 40.1 pNN50 (%) 4.2 4.5 6.3 TI 9.9 11.9 9.2 Heart rate (bpm) 62 65 62 CV (%) 3.80 6.16 4.15 RRmin (ms) 888 820 872 RRmax (ms) 1080 1096 1128 X (s) 0.19 0.28 0.26 IN (% / s ^ 2) 133.9 69.7 99.7 Total (ms ^ 2) 576 1198 490 VLF (ms ^ 2) 259 834 211 LF (ms ^ 2) 297 317 242 HF (ms ^ 2) twenty 47 38 VLF (%) 45 69 43 LF (%) 52 27 49 HF (%) 3 four 8 LF / HF 15.18 6.67 6.41 N 307 309 303 IC 28 24 12

Figure 3 presents the interval cardiogram at rest, with lumbar puncture and in the recovery period after the test.

Figure 4 - histograms, tablegrams and power spectra at rest, during and after the sample.

Conclusion: at rest, intense sympathicotonia is observed, with lumbar puncture, intense sympathicotonia with some increase in NECS, and after the test, intense sympathicotonia with a decrease in NECS to moderate, with VLF <50% and a decrease in sympathetic effects. This state with SORS = + 7. Lack of reactivity of the ANS.

At the end of the acute period (after 21 days), the patient was discharged in a compensated state without hypertension-hydrocephalic syndrome and gross focal symptoms.

Example 3. Patient K., 61 g., And / b No. 120, was admitted to the RNHI on the 4th day of ventricular hemorrhage. Upon admission, the condition is serious, compensated for by vital functions. Neurologically expressed hypertensive and meningeal syndromes, bilateral pyramidal insufficiency, more to the right. Upon additional examination with CT AH, data for AA, AVM were not obtained, the etiology of hemorrhage was regarded as hypertonic and atherosclerotic. During his stay in the hospital, the patient's condition was unstable, there were signs of a diencephalic-catabolic syndrome (hypertension, hyperthermia to febrile digits), stem symptoms (incomplete Parino syndrome, dysphonia, dysarthria, dysphagia) with subsequent regression. On the 21st day of the acute period, the patient underwent lumbar puncture against the background of the recording of an interval cardiogram with blood pressure = 140/90 mm Hg, CSF pressure = 230 mm Hg. (hypertension). Cardiac rhythmogram indicators are presented in table 4.

Table 4 Peace Lumbar puncture Recovery SDNN (ms) 39.0 46.1 34.7 pNN50 (%) 2.3 0.0 0.0 TI 6.8 7.9 6.5 Heart rate (bpm) 78 88 85 CV (%) 5.05 6.76 4.93 RRmin (ms) 688 580 648 RRmax (ms) 900 812 812 X (s) 0.21 0.23 0.16 IN (% / s ^ 2) 152.8 151.9 241.4 Total (ms ^ 2) 425 773 900 VLF (ms ^ 2) 313 718 854 LF (ms ^ 2) 90 53 40 HF (ms ^ 2) 22 3 5 VLF (%) 74 93 95 LF (%) 21 7 four HF (%) 5 0.4 one LF / HF 4.06 08/18 7.96 N 387 585 412 IC 18.0 257.0 179.0

Figure 5 presents the interval cardiogram at rest, with lumbar puncture and in the recovery period after the test.

Figure 6 - histograms, tablegrams and power spectra at rest, during and after the sample.

Conclusion: at rest, intense sympathicotonia is observed, which persists both during lumbar puncture and in the recovery period after the test with a pronounced CVEC (VLF> 50%, LF / HF> 2.5), with SORS = + 7 (overvoltage state) . Inadequate ANS reactivity - exhaustion.

In connection with the development of hypertension-hydrocephalic syndrome, the patient underwent ventriculoperitoneal shunting (CHPS). After IPS, positive dynamics were noted, the patient was discharged, however, in the recovery period - at the 4th month after hemorrhage, the patient died of acute myocardial infarction.

Using the inventive method provides the ability to assess the reactivity of the ANS in patients in the acute period of NIHC with varying degrees of severity of cerebral and focal symptoms undergoing medical anesthesia, as well as improving the accuracy of identifying adaptive capabilities of the body with determining the variant course of the disease and allows you to identify the correlation of the degree of tension of suprasegmental centers the presence of hypertension-hydrocephalic syndrome.

Evaluation of the pathogenetic mechanisms of the degree of NVVC by the contribution of very slow waves in patients with intracranial hypertension depending on lateralization and type of hemorrhage in the analysis of heart rate variability before, during and after lumbar puncture, performed according to indications, is the earliest criterion for predicting the course of the disease and treatment effectiveness (medical and surgical), which provides an increase in the accuracy of diagnosis of deviations arising in regulatory systems preceding gross hemodi amicheskim, metabolic disorders, and energy.

Claims (1)

A method for assessing the reactivity of the autonomic nervous system (ANS) in the acute period of intracranial hemorrhage, including recording the cardiointervalogram at rest, during the test and during the recovery period after the test, as well as conducting a temporary analysis of cardiocycles, the rhythm wave structure and a comprehensive assessment of regulatory systems, characterized in that a lumbar puncture is used as a sample with measurement of cerebrospinal fluid pressure and in the absence of intracranial hypertension and a decrease in the contribution of very slow ln (VLF) after the test, if intense rest vagotonia during a puncture goes into a tense balance, and during a recovery period into intense vagotonia, a tense balance or a stress-free balance, or if a tense rest balance is maintained during a puncture and goes into a balance without stress in the recovery period, or if the balance at rest goes into intense vagotonia and balance in the recovery period - the reactivity of the ANS is assessed as adequate; in the presence of intracranial hypertension or its absence and with a VLF of more than 30% after the test, if the tense rest balance during puncture goes into intense sympathicotonia, and then in the recovery period into tense balance or tense sympathicotonia, or tense rest sympathicotonia goes into tense sympathicotonia in the recovery period with a decrease in VLF - ANS reactivity is assessed as inadequate, insufficient, in the presence of intracranial hypertension, if vagotonia during puncture and in recovery ode becomes hard vagotonia or sympathicotonia sympathicotonia in hard or hard and hard vagotonia sympathicotonia rest does not change during and after the test, there is an increase or VLF contribution of more than 50% - reactivity of the ANS is estimated to be inadequate exhausted.

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