RU2397710C1 - Method of prognosis outcome of severe craniocerebral injury at supratentorial brain compression - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery, neurotraumatology. Digitisation of gradation of signs identified at examining the patient is carried out. Gradation of signs are evaluated in points. The total risk score (SUM) is calculated by the formula: SUM = X1 + X2 + X3 + X4, where X1 is the stage of traumatic dislocation syndrome: I stage - 1 point, II stage - 2 points, III stage -3 points, IV stage - 4 points, V stage - 5 points; X2 is the percentage of reduction in average arterial blood pressure (AABP) in the preoperational and operational periods in relation to the original AABP: reduction of less than 10% - 0 points, 10-24% - 1 point, 25-40% - 2 points, more than 40% - 6 points; X3 is the percentage of AABP reduction in the postoperative period in relation to the original with AABP: decline or equal to 10% - 0 points, 11-20% - 1 point, 21% or more - 2 points; X4 is presence of septic complications: No - 0 points, pneumonia - 1 point, meningoencephalitis - 2 points. With the value of SUM is less than 4, a favorable outcome is predicted, and at the value of SUM equal to or more than 4, fatal outcome of severe traumatic brain injury is predicted.

EFFECT: method enables to improve prognosis accuracy and simplify the calculation procedure.

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Description

The invention relates to medicine, namely to neurosurgery, neurotraumatology, clinical neurology (neuropathology), and can be used to determine the prognosis of the outcome of supratentorial compression of the brain in severe traumatic brain injury (BMI).

A known method for predicting the outcome of PMI (Zotov Yu.V., Schedrenok VV Surgery of traumatic intracranial hematomas and centers of crushing of the brain. - L., Medicine, 1984. - S.140-141), based on the unification of estimates of the severity of the injury, allowing to calculate the expected outcomes of treatment for the contingent of patients with different structures of the head injury. To determine the possible mortality (in%) of the total contingent, use the formula

,

,

where E is the outcome, fi is the relative frequency of patients of the i-th group according to

diagnostic scale or other unified scale for assessing severity among all patients of this contingent, i = 1, 2, ..., n is the group number on the severity scale, pi is the probability (relative frequency) of the outcome for patients of the i-th group in the general population.

The disadvantages of the method: the formula is cumbersome and complex, and also includes many derivatives that require preliminary calculations.

A known method for predicting the outcome of PMTCT (Kondakov EN Diagnostics and differentiated tactics of surgical interventions in case of severe traumatic brain injury. Diss. Doctor of Medical Sciences. - L., 1993. - 208 p.), Based on the analysis of prognostic value 36 possible options, the three most significant and always noted neurological signs: the background size of the pupils, the presence of pupil photoreaction, the characteristics of the motor reaction to the pain stimulus. With this method, the option of combining signs is evaluated twice - before treatment, as well as in the first 5 days of treatment (at the best). The probability of an adverse outcome is calculated based on the number of the syndrome. The prognostic significance of each syndrome is set in the "survival" points: the ratio of the number of "discharged" patients to the number of cases of this syndrome in the clinic before ("f1") and 1-5 days after ("f2") operations. The prognosis of outcomes is based on a quantitative assessment of neurological status, expressed in "outcome score" and the magnitude of the displacement of the anterior cerebral artery - PMA - according to carotid angiography, calculated by the formula

Z = outcome score + 0.5 × PMA.

A favorable treatment outcome is predicted with Z over 46, and a fatal outcome with Z less than 46.

Diagnostic accuracy in the case of predicting favorable outcomes is 80%, while forecasting unfavorable outcomes is 66.6%.

The disadvantages of the method: low diagnostic accuracy, the need for carotid angiography, which has certain contraindications in patients with PMTCT and requires a certain time.

A known method for predicting the outcome of PMTCT (Likhterman L.B., Kornienko V.N., Potapov A.A., Kuzmenko V.A., Gorbunov V.I., Troshin V.M. Craniocerebral trauma: prognosis of the course and outcomes . - M .: Book LTD, 1993. - P.195). To determine prognostic informational content, 26 clinical symptoms are used that characterize the patient’s condition at the time of surgery and the final outcome — favorable and fatal. Using a computer, out of 26 signs, 13 of the most informative were identified: age of patients, hospitalization, state of consciousness, vomiting, type of breathing, blood pressure, body temperature, gaze up, nystagmus, pupil reaction to light, paresis of limbs, convulsive syndrome, stiff neck with the number of gradations of each feature from 3 to 8. All of these 13 features are entered in a table where a prognostic coefficient is indicated against each gradation of each feature (the decision rule is based on a linear minimax algorithm). After identifying the victim of all the signs listed in the table, their prognostic factors are summarized. The received amount (D) characterizes the forecast at the time of the operation. With D more than 24 there is a risk of death, with D less than 16 there is no risk of death; with D more than 16 and less than 24, the probability of death and survival is the same. Testing this algorithm on an examination sample showed that the diagnostic accuracy of the method is 75%.

The disadvantages of the method: low accuracy of the forecast, the need to assess a large number of signs, a large number of gradations of signs, which makes the calculations time-consuming.

A known method for predicting the outcome of PMI (Patent of the Russian Federation No. 2199941, 2003, bull. No. 7), adopted by us for the prototype. During the initial clinical and neurological examination of a victim with severe traumatic brain injury, the numerical values of the gradations of the five most prognostically significant clinical and neurological signs selected using correlation and step-by-step discriminant analyzes are determined in the in-patient department of the hospital. Calculate the linear discriminant functions corresponding to two outcomes of severe TBI - favorable (LDF1) and lethal (LDF2) according to the formulas

LDF1 = 1.90X1 + (- 0.19) (X2 + 7.53X3 + 13.63X4 + 23.97X5 + (- 51.41),

LDF2 = 2.51X1 + 0.10X2 + 8.40X3 + 14.41X4 + 23.05X5 + (- 58.27),

where X1 is the age determined by 7 gradations;

X2 - systolic blood pressure in 5 gradations;

X3 - consciousness in 7 gradations;

X4 - innervation of the pupils in 2 gradations;

X5 - oculocephalic reflex in 2 gradations

The outcome is determined by the prevailing absolute value of one of the two linearly discriminant functions. The diagnostic accuracy of the method is 80.95%.

The disadvantages of the prototype: not enough high accuracy of the forecast, complex formulas of linearly discriminant functions and time-consuming calculation.

The invention is aimed at creating a method for predicting the outcome of PMTCT with supratentorial compression of the brain, which allows to increase the accuracy of the forecast, simplify the calculation procedure and reduce its time.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method for predicting the outcome of PMTCT with supratentorial compression of the brain, including digital coding of gradations of symptoms identified during examination of the patient, and calculating the digital value of the clinical and neurological status that determines the prognosis, the feature is that that gradations of signs are evaluated in points, the total risk score (SUM) is calculated according to the formula

SUM = X1 + X2 + X3 + X4,

Where

X1 - stage of traumatic dislocation syndrome, determined by 5 gradations with the following digital values: stage I - 1 point, stage II - 2 points, stage III - 3 points, stage IV - 4 points, stage V - 5 points;

X2 - percentage reduction in mean arterial pressure (SBP) in the preoperative and operational periods in relation to the initial SBP cf, in 4 grades: less than 10% - 0 points, 10 -24% - 1 point, 25-40% - 2 points, more 40% - 6 points;

X3 - percentage reduction in the postoperative CAD from the initial CAD, determined by 3 gradations: less than 10% - 0 points, 10-20% - 1 point, 21% or more - 2 points;

X4 - the presence of purulent complications (meningoencephalitis and pneumonia), in 3 grades: no - 0 points, pneumonia - 1 point, meningoencephalitis - 2 points, a favorable treatment outcome is predicted with SUM less than 4, lethal - with SUM is equal to or more than 4.

The method is as follows. Clinical and neurological examination of a victim with supratentorial compression of the brain due to PMI determines the gradation of four prognostically significant signs (X1, X2, X3, X4), each of which has a digital value in points.

1) X1 - stage of traumatic dislocation syndrome (TDS) (E.N. Kondakov, A.V. Klimash, A.K. Bakhtiyarov, V.D. Bokin. Supratentorial traumatic dislocation of the brain (clinical, neurological and morphological aspects) / / “Neurological Bulletin Journal named after V.M. Bekhterev.” - 2008. - Issue 3. - S.19-24):

1 gradation - TDS stage I - 1 point; 2 gradation - TDS II stage - 2 points;

3 gradation - TDS stage III - 3 points: 4 gradation - TDS stage IV - 4 points; 5th gradation - TDS V stage - 5 points

2) X2 is the percentage reduction in mean arterial pressure (SBP) in the preoperative and operational periods in relation to the initial blood pressure:

1 gradation - less than 10% - 0 points; 2 gradation - 10-24% - 1 point; 3 gradation - 25-40% - 2 points; 4 gradation - more than 40% - 6 points

3) X3 percent reduction in CAD in the postoperative period relative to the initial CAD:

1 gradation - less than 10% - 0 points; 2 gradation - 10-20% - 1 point;

3 gradation - more than 20% - 2 points

4) X4 - the presence of purulent complications (meningoencephalitis and pneumonia):

1 gradation - no complications - 0 points

2 gradation - pneumonia - 1 point

3 gradation - meningoencephalitis - 2 points

The gradation points of all the signs listed above revealed in a particular victim arithmetically summarize and calculate the total risk score (SUM) SUM = X1 + X2 + X3 X4. If the SUM is less than 4, then the patient’s survival forecast will be statistically reliable, in cases where the SUM is equal to or more than 4, the prognosis of a fatal outcome will be statistically reliable.

The proposed method for predicting the outcome of PMTCT with supratentorial compression of the brain was developed at the Russian National Scientific Research Institute of Cardiology. prof. A.L. Polenova and passed clinical trials in predicting treatment outcomes for 287 patients. Diagnostic accuracy, sensitivity, specificity, as well as positive and negative predictivity of the proposed method are presented in the table.

Table No. p / p Key statistics Values one Diagnostic accuracy 93.7% 2 Sensitivity 96% 3 Specificity 91.2% four Positive Forecast 92.4% 5 Negative Predictability 95.4%

We give examples - extracts from medical records.

Example 1. Patient P., 64 years old, and / b 28541-06, was delivered to the emergency room 1 hour after receiving a traumatic brain injury in an accident. On admission: the state is extremely serious, depression of consciousness - coma I, vital functions are compensated, blood pressure 150/90 mm Hg, independent breathing, clinically effective. In the study of neurological status revealed a traumatic dislocation syndrome of stage II (X1 = 2 points). After a standard examination, the patient revealed supratentorial compression of the left hemisphere of the brain with an acute subdural hematoma of the left frontotemporal region of 80 ml. On an emergency basis, according to the patient’s vital indications, decompressive trepanation of the skull in the left frontotemporal region, removal of the hematoma was performed. At the stage of opening the dura mater, the patient showed a decrease in average BP by 12% compared with the initial value (X2 = 1 point). In the postoperative period, episodes of hypotension were not recorded, purulent complications were not (X3 = 0 points, X4 = 0 points). Taking into account the severity of the above signs, a total risk score was calculated by simple arithmetic addition: SUM = X1 + X2 + X3 + X4 = 2 + 1 + 0 + 0 = 3 points; the calculation results indicated a favorable outcome, because SUM less than 4. On the 23rd day after the operation, the patient was discharged in a compensated state for outpatient treatment. Thus, the presented calculations of the prognosis of treatment outcome of this patient, based on 4 clinical signs obtained during examination of the patient, coincided with the real result of treatment.

Example 2. Patient P., 52 years old, and / b 4899-07, was taken to the hospital due to a traumatic brain injury as a result of a blow to the head with a solid object. On admission: the condition is extremely serious, blood pressure 170/100 mm Hg subcompensated for vital functions, periodic breathing, depression of consciousness - coma II. In the study of neurological status revealed a traumatic dislocation syndrome of stage III (X1 = 3 points). After computed tomography of the brain, the patient revealed supratentorial compression of the right hemisphere of the brain with an acute subdural hematoma of the right frontotemy temporal volume of 160 ml. In an emergency, according to vital indications, the patient underwent decompressive trepanation of the skull in the left frontotemporal region, removal of the hematoma. At the stage of opening the dura mater, there was a decrease in blood pressure of the mean by 7% compared with the initial value (X2 = 0 points). In the postoperative period, on the 2nd day, an episode of a decrease in blood pressure of an average of 43% was recorded (X3 = 2 points). There were no purulent complications (X4 = 0 points). Taking into account the severity of the above signs, by a simple arithmetic addition, the total risk score SUM = X1 + X2 + X3 + X4 = 3 + 0 + 2 + 0 = 5 points was calculated; calculation results indicated an unfavorable outcome, as SUM more than 4. On the 5th day of hospitalization, the patient was diagnosed with cardiac arrest, resuscitation measures were ineffective, and ultimately the patient's death was ascertained.

The advantages of the proposed method compared to the prototype.

1. Improving the diagnostic accuracy of the outcomes - 93.7% instead of 80.95%:

a) due to the inclusion in the statistical processing of a homogeneous group of patients - patients with supratentorial compression of the brain, and not patients with the entire BMI, including both compression of the brain and its diffuse primary injury;

b) due to the application of the method of constructing classification trees, which allows to efficiently combine qualitative and quantitative characteristics of the patient’s condition in the algorithm.

2. Simplification of prediction calculation and reduction of its time due to simple arithmetic addition of four digits from 0 to 5, instead of complex calculations of linearly discriminant functions based on cumbersome formulas.

Claims (1)

A method for predicting the outcome of severe traumatic brain injury with supratentorial compression of the brain, including digital coding of gradations of symptoms identified during the examination of the patient and calculating the digital value of the clinical and neurological status, which determines the prognosis, characterized in that gradations of symptoms are evaluated in points, calculate the total risk score (SUM) by the formula: SUM = X1 + X2 + X3 + X4, where
X1 - stage of traumatic dislocation syndrome: stage I - 1 point, stage II - 2 points, stage III - 3 points, stage IV - 4 points, stage V - 5 points;
X2 - percentage reduction in mean arterial pressure (SBP) in the preoperative and operational periods in relation to the initial blood pressure: a decrease of less than 10% - 0 points, 10-24% - 1 point, 25-40% - 2 points, more than 40% - 6 points;
X3 - percentage of decrease in CAD in the postoperative period in relation to the initial CAD: decrease or equal to 10% - 0 points, 11-20% - 1 point, 21% or more - 2 points;
X4 - the presence of purulent complications: no - 0 points, pneumonia - 1 point, meningoencephalitis - 2 points,
and with a SUM value of less than 4, a favorable outcome is predicted, and with a SUM value of equal to or greater than 4, a fatal outcome of severe traumatic brain injury is predicted.