RU2433782C2 - Method of predicting brain dislocation in case of its compression - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurology and radiodiagnostics and is intended for detection of brain dislocation in case of its compression. CT examination of brain is performed. Measured are distances between lateral parts of anterior horns of lateral ventricles and maximal distance between internal plates of scull bones at said level; width of lateral ventricles at the level of heads of caudate nuclei and maximal distance between internal plates of scull bones at said level; and width of III ventricle and maximal distance between internal plates of scull bones at said level. After that, by given formulas calculated are ventriculo-cranial indices: VCI 1 of anterior horns of lateral ventricles, VCI 2 of lateral ventricles at the level of heads of caudate nuclei, VCI 3 of ventricle. After that, calculated is hypertension coefficient (HC) by formula:

where VCI_p are patient's ventriculo-cranial indices, VCI_n are age norms of ventriculo-cranial indices for this particular patient; and if HC value is from -1 to -3, prognosis is alarming, dislocation syndrome is expressed moderately, patient is in decompensation phase, intensive therapy is required; if HC value is lower than -3, dislocation is expressed, urgent surgical treatment is required.

EFFECT: method makes it possible to detect brain dislocation in case of its compression, control its development and dynamics in course of carrying out resuscitation and treatment of patients in hospital.

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Description

The invention relates to medicine and can be used in neurosurgery, neurology, traumatology, neuroresuscitation and radiation diagnostics as a method of constructing a protocol for the treatment of intracranial hypertension syndrome and brain dislocation during compression.

A known method for predicting the adverse course and outcomes of severe traumatic brain injury based on the registration of electrophysiological parameters. The authors investigated somatosensory evoked potentials and acoustic stem evoked potentials in patients with severe traumatic brain injury on days 1-3 and 5-7 after admission. In primary or secondary damage to the brain stem, an early criterion for an adverse outcome is the unilateral or bilateral absence of the N20 component of short-wave somatosensory evoked potentials, the absence of II-V waves on acoustic stem evoked potentials (Gurskaya O.E., Belyakov N.A., Danilevich M.O. Evoked potentials of the brain as criteria for predicting severe traumatic brain injury // Neurosurgery, 2008. No. 4, p.30-37). The main disadvantage of this method is a statement of the already completed dislocation of the brain stem, which leaves no chance of preventive therapy with intracranial hypertension beginning with the threat of developing brain dislocation.

A known method for predicting a traumatic brain injury for the diagnosis of brain dislocation (Patent RU No. 2210321, "Method for the diagnosis of brain dislocation"). The authors record the linear velocity of cerebral blood flow using transcranial dopplerography, during which a carotid-compression test is performed and pre- and post-compression blood flow velocities are determined. At a post-compression speed lower than decompression by 10%, the temporal dislocation of the brain is diagnosed, which is regarded as an unfavorable sign. This method determines a complication that has already arisen with a known unfavorable prognosis and does not allow one to determine the conditions preceding this complication, the period between a favorable and unfavorable outcome, i.e. a time when it is still possible through specific therapy to prevent the dislocation of the brain and cure the patient. According to the technology of the method, it is necessary to compress the carotid artery, which is fraught with a complication in the form of impaired cerebral circulation.

Closest to the claimed one is a method for determining the cerebrospinal fluid index measured by the Volume program from the software of the third generation CT-9000 HP computed tomograph by General Electric (V.I. Larkin, V.P. Atroshenko, I.I. .Larkin. The concept of acute craniocerebral imbalance in the treatment of traumatic brain injury in children // Materials of the annual scientific and practical conference of neurologists and neurosurgeons; Omsk, 2004). The technique is based on a quantitative determination of tissue volumes at given densimetric intervals, expressed in Hounsfield units. The disadvantages of this method are: 1) a reflection of the state of the cerebrospinal fluid spaces of the brain reveals only a disproportion in the volume of the cranial cavity and volumes of cerebrospinal fluid and brain substance; 2) using the method it is impossible to determine the presence or absence of a brain dislocation, developing in the presence of volumetric formations with progressive cerebral edema; 3) the method is developed for children's practice.

The objective of the invention is the early, before the development of irreversible complications, predicting the dislocation of the brain with progressive intracranial hypertension, which allows you to adjust the pathological process at the stage of reversible complications.

The problem is solved due to the fact that they measure the distance between the lateral sections of the anterior horns of the lateral ventricles and the maximum distance between the inner plates of the cranial bones at this level, the width of the lateral ventricles at the level of the heads of the caudate nuclei and the maximum distance between the internal plates of the skull bones at this level, the width III ventricle and the maximum distance between the inner plates of the bones of the skull at this level, calculate the ventriculo-cranial index 1 (FRI 1) of the anterior lateral horns ventricles according to the formula: A ₁ / B ₁ × 100%, where A ₁ is the distance between the lateral sections of the anterior horns of the lateral ventricles, B ₁ is the maximum distance between the inner plates of the skull bones at this level; calculate the ventriculo-cranial index 2 (FRI 2) of the lateral ventricles at the level of the heads of the caudate nuclei according to the formula: A ₂ / B ₂ × 100%, where A ₂ is the width of the lateral ventricles at the level of the heads of the caudate nuclei, B ₂ is the maximum distance between the inner plates skull bones at this level; calculate the ventriculo-cranial index 3 (FRI 3) of the III ventricle according to the formula: A ₃ / B ₃ × 100%, where A ₃ is the width of the III ventricle, B ₃ is the maximum distance between the inner plates of the bones of the skull at this level;

determine the deviations of FRI 1, 2 and 3 from the age norm of the patient;

calculate the coefficient of hypertension (KG) by the formula:

where VKI _b - ventriculo-cranial indices of the patient,

FRI _n - ventriculo-cranial indices taking into account the age norm for the patient; and with a value of CG with a plus sign, a favorable outcome is predicted, the patient is in the phase of clinical compensation or subcompensation, there are no signs of dislocation, the treatment is conservative; with a CG value from -1 to -3, the prognosis is alarming, the dislocation syndrome is moderate, the patient is in the decompensation phase, intensive therapy is required; with a CG value less than -3, a dislocation syndrome is expressed, urgent surgical intervention is required.

The implementation of this method allows you to control the development and dynamics of the dislocation of the brain during its progressive edema during resuscitation and treatment of patients in the hospital, to monitor the effectiveness of surgical interventions at any time after surgery and to predict the course of the postoperative period with planned neurosurgery, since any surgical intervention on the brain is identical to traumatic injury. The implementation of the method allows for preventive therapy of possible complications and timely correction of treatment, which not only saves the lives of patients, but also their quality of life.

The technical result is achieved by monitoring the state of the ventricles of the brain and the ratio of their volumes with the volume of the skull.

The invention is illustrated by drawings. Figure 1 illustrates a measurement for calculating the ventriculo-cranial index of the anterior horns of the lateral ventricles, A is the measured distance between the lateral portions of the anterior horns of the lateral ventricles, Figure 2 is a measurement for calculating the ventriculo-cranial index of the bodies of the lateral ventricles, C is the measured width of the lateral ventricles. ventricles at the level of the heads of the caudate nuclei; and FIG. 3 is a measurement for calculating the ventriculo-cranial index of the third ventricle, D is the measured width of the third ventricle.

The method is as follows: on the first day of the injury, the patient undergoes computed tomography of the brain on a multispiral computed tomograph in a spiral scan mode with a reconstruction layer thickness of 1.5 mm. Measurements are made in soft tissue mode on axial scans. Then the calculation of the ventriculo-cranial indices (FRI) by the formula: FRI = A / B × 100%.

First, the index of the anterior horns of the lateral ventricles is determined, for which the distance (Figure 1, A) between the lateral sections of the anterior horns of the lateral ventricles is measured - A ₁ , the maximum distance between the inner plates of the bones of the skull at this level is B ₁ , and FRI 1 is calculated by the formula : FRI1 = A ₁ / B ₁ × 100%. Then, the index of the bodies of the lateral ventricles is determined, for which the width (Figure 2, C) of the lateral ventricles at the level of the heads of the caudate nuclei is measured - A ₂ , the maximum distance between the inner plates of the bones of the skull at this level is B ₂ , and the FRI 2 is calculated by the formula: FRI 2 = A ₂ / B ₂ × 100%. Then, the index of the third ventricle is determined, for which the width (Fig. 3, D) of the third ventricle is measured - A ₃ , the maximum distance between the inner plates of the bones of the skull at this level is B ₃ , FRI 3 is calculated by the formula: FRI 3 = A ₃ / B ₃ × 100%. The patient's FRI is compared with the upper limits of the norm in each age group (Table) and deviations from the patient's age norm are determined.

Table Age norms of ventriculo-cranial indices (FRI _n ) Indexes (%) Age groups > 30 31-40 41-50 51-60 61-70 > 70 FRI 1 26,4 29.4 WKI 2 16 17 eighteen 19 twenty 21 WKI 3 2.7 2.9 3,1 3,5 3.9 4.3

The hypertension coefficient (KG) is calculated by the formula:

where VKI _b is the calculated ventriculo-cranial index of the patient;

FRI _n - age norm of the ventriculo-cranial index for a given patient.

With a hypertension coefficient with a plus sign (+), regardless of the digital value, patients with brain compression are in the phase of clinical compensation or subcompensation, there are no signs of dislocation, the treatment is conservative and the prognosis is always favorable.

When the hypertension coefficient is from -1 to -3, the dislocation syndrome is moderately expressed, patients with brain compression are in the phase of moderate decompensation, the prognosis is alarming. This is an indicator of the possibility of improving the patient's condition and a favorable outcome with timely and complete intensive care. Conservative treatment is possible, but with constant monitoring of FRI. If the therapy is incomplete or untimely, the coefficient of hypertension decreases, and the prognosis becomes unfavorable.

When the hypertension coefficient is less than -3, dislocation syndrome is expressed, patients with brain compression are in the phase of gross decompensation, and conservative therapy is ineffective, urgent decompression trepanation is required with the removal of the substrate that compresses the brain.

Examples of specific applications of the method

Example No. 1. Patient D., 49 years old. She was admitted to the neurosurgical department of the Municipal Clinical Hospital No. 34 with a diagnosis of brain contusion of moderate severity, with compression of the brain of a small acute subdural hematoma of the right parietal-temporal region. Clinically, the syndrome of intracranial hypertension without signs of brain dislocation. When computed tomographic examination on a multispiral computed tomography (Siemens Somatom Emotion 16) in a spiral scan mode with a reconstruction layer thickness of 1.5 mm revealed acute subdural hematoma and signs of intracranial hypertension.

The distance between the most lateral sections of the anterior horns of the lateral ventricles (A ₁ = 3.26 cm), the maximum distance between the inner plates of the cranial bones at this level (B ₁ = 12.13 cm) were measured. According to the formula FRI = A / B × 100%, the calculation was made: 3.26 / 12.13 × 100% = 27%. Then, the width of the lateral ventricles was measured at the level of the heads of the caudate nuclei (A ₂ = 1.78 cm) and the maximum distance between the inner plates of the bones of the skull at this level (B ₂ = 11.99 cm). The FRI 2 was calculated using the same formula: 1.78 / 11.99 × 100% = 14.8%. Then, the width of the third ventricle was measured (A ₃ = 0.35 cm), the maximum distance between the inner plates of the bones of the skull at this level (B ₃ = 2.48 cm) and the FRI 3 was calculated using the same formula: 0.35 / 12, 48 × 100% = 2.8%.

The deviation from the age norm for each FRI is determined:

FRI 1: 27.0-26.4 = 0.6

FRI 2: 14.8-18.0 = -3.2

FRI 3: 2.8-3.1 = -0.3

Then calculated the coefficient of hypertension (KG):

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The next CT scan was performed on the 8th day after the injury; moderately pronounced negative dynamics was observed in the form of an increase in signs of intracranial hypertension. The distance between the most lateral sections of the anterior horns of the lateral ventricles (A ₁ = 3.15 cm), the maximum distance between the inner plates of the cranial bones at this level (B ₁ = 12.58 cm) were measured. Using the formula, the FRI 1: 3.15 / 12.58 × 100% = 25% was calculated. Then, the width of the lateral ventricles was measured at the level of the heads of the caudate nuclei (A ₂ = 1.64 cm) and the maximum distance between the inner plates of the bones of the skull at this level (B ₂ = 12.07 cm) and the FRI 2 was calculated: 1.64 / 12, 07 × 100% = 13.6%. Then, the width of the third ventricle was measured (A ₃ = 0.36 cm), the maximum distance between the inner plates of the bones of the skull at this level (B ₃ = 2.68 cm, and FRI 3 was calculated: 0.36 / 12.68 × 100% = 2.8%.

Deviations from the age norm for each FRI are determined:

FRI 1 = 25.0-26.4 = -1.4;

FRI 2 = 13.6-18.0 = -4.4;

FRI 3 = 2.8-3.1 = -0.3;

Then calculated the coefficient of hypertension (KG):

and adjusted infusion therapy: mannitol solution was administered for 3 days.

A CT study showed positive dynamics in the form of a decrease in the size and density of the hematoma 14 days after the correction of therapy. The distance between the most lateral sections of the anterior horns of the lateral ventricles (A ₁ = 3.39 cm), the maximum distance between the inner plates of the bones of the skull at this level (B ₁ = 12.19 cm) were measured. The FRI 1: 3.39 / 12.19 × 100% = 27.8% was calculated. Then, the width of the lateral ventricles was measured at the level of the heads of the caudate nuclei (A ₂ = 1.8 cm) and the maximum distance between the inner plates of the skull bones at this level (B ₂ = 12.03 cm). Calculated FRI 2: 1.8 / 12.03 × 100% = 15%. Then, the width of the third ventricle was measured (A ₃ = 0.5 cm), the maximum distance between the inner plates of the bones of the skull at this level (B ₃ = 12.65 cm), and the FRI 3 was calculated: 0.5 / 12.65 × 100% = 4%.

The deviation from the age norm for each FRI is determined:

FRI 1 = 27.8-26.4 = 1.4

FRI 2 = 15.0-18.0 = -3.0

FRI 3 = 4.0-3.1 = 0.9

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Thus, according to the FRI, patient D. had moderate intracranial hypertension (KG = -1) upon admission, and after 8 days intracranial hypertension increased, which was accompanied by moderate axial dislocation (KG = -2.3).

The intensive therapy carried out taking into account these data made it possible to stop intracranial hypertension and dislocation (KG = -0.2) after 21 days.

Example No. 2. Patient R., 31 years old, was admitted to the neurosurgical department of the Municipal Clinical Hospital No. 34 with a diagnosis of brain injury of moderate severity, brain compression with a subacute subdural hematoma in the right frontotemporal region. During the initial computed tomography study, subacute subdural hematoma, single contusion-hemorrhagic foci, signs of lateral and axial dislocation, signs of intracranial hypertension were revealed. The distance between the most lateral sections of the anterior horns of the lateral ventricles A ₁ = 3.08 cm, the maximum distance between the inner plates of the bones of the skull at this level B ₁ = 12.72 cm was measured. Using the formula FRI = A / B × 100, FRI 1 was calculated: 3.08 / 12.72 × 100% = 24.2%. Then, the width of the lateral ventricles at the level of the heads of the caudate nuclei A ₂ = 1.27 cm and the maximum distance between the inner plates of the bones of the skull at this level B ₂ = 12.52 cm were measured. The FRI 2 was calculated using the same formula: 1.27 / 12, 52 × 100% = 10.0%. Then the width of the third ventricle A ₃ = 0.32 cm was measured, the maximum distance between the inner plates of the bones of the skull at this level was B ₃ = 2.72 cm, and the FRI 3 was calculated: 0.32 / 12.72 × 100% = 2.5 %

Deviations from the age norm for each FRI are determined:

FRI 1: 24.2-26.4 = -2.2

FRI 2: 10.0-17.0 = -7.0

FRI 3: 2.5-2.9 = -0.4

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Intensive therapy was carried out with correction of respiration and hemodynamics, antihypertensive therapy. A repeat CT scan after 3 days showed a negative trend in the form of an increase in signs of intracranial hypertension, an increase in the dislocation syndrome. The distance between the most lateral sections of the anterior horns of the lateral ventricles was measured: A ₁ = 3.02 cm, the maximum distance between the inner plates of the cranial bones at this level: B ₁ = 12.61 cm. The FRI was calculated using the formula FRI = A / B × 100 1: 3.02 / 12.61 × 100% = 23.9%. Then, the width of the lateral ventricles was measured at the level of the heads of the caudate nuclei: A ₂ = 1.03 cm and the maximum distance between the inner plates of the bones of the skull at this level: B ₂ = 12.71 cm. The FRI 2 was calculated using the same formula: 1.03 / 12.71 × 100% = 8.1%. Then, the width of the third ventricle was measured: A ₃ = 0.21 cm, the maximum distance between the inner plates of the bones of the skull at this level: B ₃ = 12.83 cm, and FRI 3 was calculated: 0.21 / 12.83 × 100% = 1 , 6%.

The deviation from the age norm for each FRI is determined:

FRI 1: 23.9-26.4 = -2.5

FRI 2: 8.1-17.0 = -8.9

FRI 3: 1.6-2.9 = -1.3

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An attempt to treat a small intracranial hematoma conservatively failed. Made osteoplastic trepanation and removal of the hematoma.

Example No. 3. Patient S., 27 years old, was admitted to the neuroresuscitation department of the Municipal Clinical Hospital No. 34 with a diagnosis of a brain contusion, a pressed fracture of the frontal bone on the left. A computed tomographic study revealed: an impressed left frontal bone fracture up to 3 mm deep, contusion-hemorrhagic foci in the fracture area, signs of subarachnoid hemorrhage, moderate lateral and axial dislocation, signs of internal neocclusal hydrocephalus, according to the proposed method, ventral indices are calculated :

FRI 1 = 29.7%, FRI 2 = 22.4%, FRI 3 = 8.4%.

Deviations from the age norm for each FRI are determined:

FRI 1 = 29.7-26.4 = 3.3

FRI 2 = 22.4-16.0 = 6.4

FRI 3 = 8.4-2.7 = 5.7

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When a CT study was repeated after 3 days, a negative dynamics was noted in the form of signs of severe intracranial hypertension, a decrease in ventriculo-cranial indices: FRI 1 = 26.7%, FRI 2 = 10.2%, FRI 3 = 1.1%.

Deviations from the age norm for each FRI:

FRI 1 = 26.7-26.4 = 0.3

FRI 2 = 10.2-16.0 = -5.8

FRI 3 = 1.1-2.7 = -1.6

The conducted intensive therapy was not effective enough and a CT follow-up study 8 days after the injury showed negative dynamics in the form of an increase in signs of intracranial hypertension, an even greater deviation of FRI (FRI 1 = 22.2%, FRI 2 = 8.8%, FRI 3 = 0.8%) of normal values:

FRI 1: 22.2-26.4 = -4.2

FRI 2: 8.8-16.0 = -7.2

FRI 3: 0.8-2.7 = -1.9

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A resection trepanation was performed with the removal of depressed bone fragments and contusion focus. 22 days after surgery, the patient's condition is satisfactory. During the control CT study, a clear positive dynamics:

FRI 1 = 27.5%, FRI 2 = 18.4%, FRI 3 = 3.2%

Deviations from the age norm for each FRI:

FRI 1 = 27.5-26.4 = 1.1

FRI 2 = 18.4-16.0 = 2.4

FRI 3 = 3.2-2.7 = 0.5

The patient was discharged in satisfactory condition.

Claims (1)

A method for detecting a dislocation of the brain during its compression by performing a CT scan of the brain, determining the ratio of the cerebrospinal fluid system to the volume of the skull, characterized in that the distances between the lateral portions of the anterior horns of the lateral ventricles and the maximum distance between the internal plates of the skull bones are measured, the width of the lateral ventricles at the level of the heads of the caudate nuclei and the maximum distance between the inner plates of the bones of the skull at this level, the width of III rod and the maximum distance between the inner plates of the skull bone at this level, is calculated ventriculo-1 cranial index (CRI 1) the anterior horn of the lateral ventricles of the formula
FRI 1 = A ₁ / B ₁ · 100%,
where A ₁ - the distance between the lateral sections of the anterior horns of the lateral ventricles;
B ₁ - the maximum distance between the inner plates of the bones of the skull at a level
calculate the ventriculo-cranial index 2 (FRI 2) of the lateral ventricles at the level of the heads of the caudate nuclei according to the formula
FRI 2 = A ₂ / B ₂ · 100%,
where A ₂ - the width of the lateral ventricles at the level of the heads of the caudate nuclei;
In ₂ - the maximum distance between the inner plates of the bones of the skull at this level,
calculate ventriculo-cranial index 3 (FRI 3) of the third ventricle according to the formula
FRI 3 = A ₃ / B ₃ · 100%,
where A ₃ is the width of the third ventricle;
In ₃ - the maximum distance between the inner plates of the bones of the skull at this level,
determine the deviations of FRI 1, 2 and 3 from the age norm of the patient;
calculate the coefficient of hypertension (KG) according to the formula

where VKI _b - calculated ventriculo-cranial indices of the patient;
FRI _n - age norms of ventriculo-cranial indices for the patient,
and with a CG value from -1 to -3, the prognosis is alarming, the dislocation syndrome is moderate, the patient is in the decompensation phase, intensive care is required; with a CG value less than -3, a dislocation syndrome is expressed, urgent surgical intervention is required.

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