RU2535039C1 - Method for prediction of clinical course of ischemic stroke in diabetic patients - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: analysed blood sample is taken that is combined with a dynamic cytofluorometrical analysis of the taken test sample for endothelial dysfunction markers - soluble adhesion molecules sICAM-1 and sVCAM-1. If the expression level of the adhesion molecules sICAM-1 is 591.9 ng/ml and more, and the expression level of sVCAM-1 is 632 ng/ml and more on the first days of a peracute period of the ischemic stroke to be persistent in dynamics or increasing in relation to the reference, the unfavourable course of ischemic stroke in the given category of patients is predicted.

EFFECT: using the method provides high sensitivity, specificity and accuracy of the prediction on the first days following the peracute period of the ischemic stroke in diabetic patients.

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Description

The invention relates to medicine, in particular to neurology, and can be used to predict the course of ischemic stroke in patients with diabetes mellitus.

In people older than 40 years, acute cerebrovascular accidents occur against diabetes mellitus one and a half to two times more often than in people who do not suffer from this disease, and under the age of 40 they are three to four times more likely, while women prevail among patients . However, little is known about the clinical course, outcomes, predictors of early mortality after ischemic stroke in people with diabetes.

Although diabetes is not a major risk factor for stroke, it can seriously complicate the course and possibilities of rehabilitation for stroke patients. Incorrect therapy for diabetes mellitus, especially in the acute period of a stroke, can significantly increase the risk of re-stroke or increase the magnitude of cerebral infarction. The acute period of ischemic stroke in patients with type 2 diabetes mellitus compared with patients with the same pathogenesis and localization of cerebral infarction, but without diabetes, is characterized by the occurrence of more severe neurological disorders, an increase in neurological deficit and its worst regression in dynamics.

Stroke in diabetes mellitus is more severe due to cerebral arterial atherosclerosis, in particular, in patients with diabetes, small arteries are also involved in the sclerosis process, therefore, the recovery period after a stroke in these patients lasts much longer and the consequences for the body are more serious than those who do not suffer diabetes mellitus. In this regard, there is a need to predict the adverse course of ischemic stroke in these patients at an earlier stage of the disease.

To date, there is a method for predicting the outcome of ischemic stroke in patients with diabetes mellitus by isolating prognostic signs in a patient: gender, age, working capacity, seasonality, previous acute cerebrovascular accident (stroke), development of stroke, the duration of the prehospital period, severity of stroke, condition consciousness, the duration of the coma, the duration of diabetes mellitus (DM), the severity of diabetes, the state of compensation for diabetes, cerebral complications of diabetes, pulmonary nausea, hypertension / symptomatic arterial hypertension, coronary heart disease, blood rheology, the extent of cerebral infarction, the condition of intracranial arteries, complicated forms of atherosclerosis. Prognostic signs are evaluated in points according to the table “Scoring signs in patients with ischemic stroke with diabetes mellitus”. The scores are summarized and, with a score of 47 and above, they predict a high probability of a lethal outcome of ischemic stroke in patients with diabetes mellitus, which makes it possible to objectively assess the severity of the patient’s condition, based on an analysis of most aspects of the pathological process, and also to select the optimal therapeutic tactics (RU 2363372, 24.09 .2007). However, this forecast method does not allow this forecast to be carried out with high accuracy in the first days of the acute period of ischemic stroke.

There is also a method for predicting the course of ischemic stroke in patients with diabetes mellitus by determining in the acute period of a stroke the level of glycosylated hemoglobin of the patient’s blood. Moreover, the presence of hyperglycemia in a patient is a poor prognostic sign (Batysheva T.T. et al. Features of the risk of stroke in patients with diabetes mellitus, Neurology and neurosurgery, published October 10, 2010, found on the Internet http://vAvw.medlinks.ru/article .php? sid = 42527). However, this method also does not have high accuracy, since it does not take into account all aspects of the development of the pathological process. This source of information is considered by the authors as the closest analogue.

The authors proposed a method for predicting the course of ischemic stroke in patients with diabetes mellitus using markers of endothelial dysfunction - soluble adhesion molecules sICAM-1 and sVCAM-1. Violation of the functional properties of the vascular wall, determined by endothelial dysfunction (ED), is one of the significant mechanisms of the pathogenesis of arterial hypertension (AH), atherosclerosis, diabetes mellitus, coronary heart disease. Cell adhesion molecules (MA) are involved in inflammatory reactions by binding activated leukocytes and mediating their rolling and migration through the endothelium into the surrounding tissue. In particular, the adhesive molecules ICAM-I, VCAM-1 initiate an increase in the permeability of intima, cell infiltration of the vessel walls by inflammatory cells and their activation, which determines the active proliferation of smooth muscle cells and their production of connective tissue, which forms the basis of the fibrous capsule of an atherosclerotic plaque. The aim of the work was to identify the content of soluble adhesion molecules in patients with acute cerebrovascular accident according to ischemic type against the background of diabetes mellitus. The study made it possible on clinical material for the first time in dynamics to study the nature of the change in the spectrum of immunological markers of inflammation in patients in the acute period of ischemic stroke with diabetes mellitus.

The technical result of the method proposed by the authors is that the use of endothelial dysfunction markers for predicting the course of ischemic stroke in patients with diabetes provides high sensitivity, specificity and accuracy of the prognosis in the first days of the acute period of ischemic stroke in this category of patients.

The technical result is achieved by the fact that in order to predict the course of ischemic stroke in patients with diabetes mellitus, an analyzed blood sample is taken, and a cytofluorimetric analysis of the obtained test sample is carried out in dynamics for the presence of endothelial dysfunction markers - soluble adhesion molecules sICAM-1 and sVCAM-1, and the value of expression levels of adhesion molecules sICAM-1 591.9 or more and sVCAM-1 632 or more in the first days of the acute period of ischemic stroke with subsequent preservation in the dynamics of these levels or their increase relative to baseline levels, an adverse course of ischemic stroke is predicted in patients with diabetes mellitus.

The method is as follows.

As immunological markers of ED, the spectrum of soluble adhesion molecules (MA) was studied in patients in the acute period of ischemic stroke and diabetes mellitus: sICAM-I- (CD 54) - intercellular endothelial adhesive molecule (intercellular adhesion molecule); sVCAM-1 (CD 106) is a soluble form of the vascular endothelial type 1 adhesion molecule (vascular cell adhesion molecule).

The study was carried out in the blood serum of patients, while the MA content was detected on a Beckman Coulter EPICS XL flow cytometer using Bender-Medsystems test systems, which make it possible to determine several MA analytes in a single blood serum sample. Using this test system, the concentration of MA sICAM-I and sVCAM-1 is determined by fluorescent microparticles conjugated with antibodies to the test sample. As a developing conjugate, streptavidin labeled with phycoerythrin is used. In the course of the study, two populations of microparticles were initially identified by light scattering parameters and each population was analyzed by fluorescence intensity (see Fig. 1 - histograms of the distribution of MA: sICAM-I and sVCAM-1). The concentration of the studied MAs is calculated according to the calibration graph of standard curves (see Fig. 2a, b - standard calibration curves for sICAM-I and sVCAM-1). Statistical processing is carried out using the standard package of applications Statistika 6.0 (Halafyan A. Statistical data analysis. STATISTICA 6.0. 2nd ed. Rev. And add. Krasnodar: KubSU, 2005. 308 s).

A study was conducted of 9 patients in the acute period (first three days) of ischemic stroke with the presence of diabetes mellitus (5 men and 4 women) aged 42 to 75 years.

When analyzing the content of soluble MA in patients in the acute period of ischemic stroke, a unidirectional character was observed in the direction of increasing both sICAM-I and sVCAM-1 by the end of 21 days (see table 1). The use of these adhesion molecules to predict the course of ischemic stroke in patients with diabetes mellitus is dictated by the fact that these MAs are immunological markers of endothelial dysfunction and are induced in the area of inflammation. Moreover, different regulation of these molecules plays an important role in the adhesion of lymphocytes in ischemic stroke. In conditions of inflammation, in particular, caused by an ischemic stroke of the brain, their expression increases under the influence of the produced pro-inflammatory cytokines. Moreover, sICAM-I MA is an early marker of inflammation, and sVCAM-1 is a type I vascular endothelial adhesion molecule and their functions are different in lymphocyte adhesion.

Table 1 Dynamics of indicators of soluble MA in the acute period of ischemic stroke in patients with diabetes mellitus. Patients with ischemic stroke with diabetes Research day sICAM-1 (ng / ml) sVSAM-1 (ng / ml) 1-3 day 816.7 [591.9; 1202] 799.0 [632; 1064] p <0.0001 n = 9 p <0.001 n = 9 21 day 824.2 [299.9; 1121] 694.3 [580; 1478] p <0.0001 n = 9 p <0.005 n = 9 Control group 253.2 [159.5; 291.5] n = 11 476.9 [342.6; 575] n = 11 Note: p <0.005, p <0.001, p <0.0001 differences in the group of patients are significant compared with the control.

The data obtained are reliable and show that the level of the intracellular adhesive molecule sICAM-1, which is important in the regulation of leukocytes and their transendothelial migration, was increased both in the acute period of the study of ischemic stroke and by the 21st day of the study. The level of expression of sVCAM-1-soluble form of vascular endothelium type 1, with relatively selective leukocyte adhesion, was also increased in the acute period of ischemic stroke, and by day 21.

A decrease in MA expression by the 21st day of ischemic stroke in patients with diabetes mellitus correlated with positive neurological dynamics. However, an increase in the concentration of MA in the blood serum of patients was combined with an unfavorable course of stroke and in some cases preceded a fatal outcome.

Thus, the high level of expression of soluble adhesion molecules sICAM-1 and sVCAM-1 in the acute period of stroke in patients with diabetes mellitus plays an important role in predicting the course of ischemic stroke in this category of patients and, accordingly, in the future in the selection of tactics for the management of these patients.

Examples of the method.

Example 1

Patient S., 50 years old, was admitted with complaints of blurred speech, weakness and numbness in his right arm and leg.

He has a history of arterial hypertension with a maximum blood pressure of 190/100 mm Hg for more than 15 years; about 10 years ago he was diagnosed with type II diabetes, and therefore he is currently taking Novomix 50 Units in the morning and evening. Acute numbness and weakness appeared in the right arm and leg, speech became fuzzy and blurry.

Objectively: a state of moderate severity. The physique is hypersthenic, of increased nutrition. The skin is pale pink, trophic changes in the legs. Lymph nodes are not enlarged. NPV 18 per minute, vesicular breathing. Heart sounds are rhythmic, muffled, heart rate 82 beats per minute, blood pressure 140/90 mm Hg The abdomen is soft, painless. Pelvic function is not impaired.

Neurological status: clear consciousness. Oriented correctly. There are no meningeal signs. Eye slots, pupils uniform. Light right hemiparesis. Muscle tone is not changed. Left-side hemipalgesia. Coordination tests are performed with intentional tremor on the right.

Biochemical analysis of blood: glucose - 17.0 mmol / L, creatinine - 62 μmol / L, cholesterol - 7.9 mmol / L, ACT - 16 U / L, ALT - 13 U / L urea - 2.92 mmol / L triglycerides 7.26 mmol / L, HDL 1.16 mol / L, LDL 3.38 mmol / L.

Brain MRI: MRI data correspond to post-infarction changes in the left cerebellar hemisphere, brain stem, cerebral hemispheres, mixed hydrocephalus. Hemorrhage in the adenohypophysis.

MP angiography: hypoplasia of the V4 region of the left vertebral artery is noted. Asymmetry of blood flow in sections A1 of the anterior cerebral arteries.

Diagnosis: Acute cerebrovascular accident with the development of a heart attack in the left cerebral hemisphere. Hemorrhage in the adenohypophysis. Encephalopathy. Common atherosclerosis. Type 2 diabetes mellitus, insulin-consuming.

On the second day of the acute period of ischemic stroke, we studied the endothelial dysfunction markers of soluble adhesion molecules sICAM-1 and sVCAM-1, the expression level of which was sICAM-872.56 ng / ml and sVCAM-819.21 ng / ml (see Fig. .3). The obtained data suggest an unfavorable course of ischemic stroke in this patient.

The patient in connection with the prognosis of an adverse course of ischemic stroke was prescribed complex intensive care. However, the patient's condition in the next days of the disease was assessed as moderate. On day 21 of the disease, a study of endothelial dysfunction markers, soluble adhesion molecules sICAM-1 and sVCAM-1, the expression level of which was sICAM-1121 ng / ml and sVCAM-1478 ng / ml, was again conducted. In the following days, the patient noted a gradual regression of neurological symptoms and stabilization of the focus of ischemia. The patient needed constant monitoring of his condition and intensive care due to the threat of possible complications, since high MA sICAM-1 and sVCAM-1 indices indicated activation of hemostasis.

Example 2

Patient N., 59 years old, was admitted with complaints of weakness in his left arm and leg, impaired gait, headache.

In the history for several years periodically notes an increase in blood pressure figures, however, he was not systematically controlled. Of chronic diseases, exacerbations of diseases of ENT organs were periodically noted. He fell ill acutely, being in a public place, noted the sudden onset of weakness in his left arm and leg, and his gait was disturbed.

Objectively: a state of moderate severity. The skin is clean, the face is slightly hyperemic, visible mucous membranes of normal color. No swelling. Lymph nodes are not enlarged. NPV 18 per minute. Heart sounds are muffled, rhythmic, heart rate 58 per minute. HELL 180/100 mm Hg The abdomen on palpation is soft, painless. The symptom of lumbar effusion is negative on both sides. Pelvic function controls.

Neurological status: Oriented, adequate. Speech is not broken. Meningeal symptoms are negative. Eye slots, pupils uniform. Photoreactions are live. The volume of movement of the eyeballs is complete, there is no nystagmus. Left-sided homonymous hemianopsia is determined. At rest and when performing facial tests, the left nasolabial fold is smoothed. When protruding, the tongue deviates to the left. The pharyngeal reflex is alive. There are no bulbar disorders. No sensory disturbances. Muscle tone is not changed. Left-sided hemiparesis (moderate in the arm and leg). Tendon and periosteal reflexes are living. In the sample, Romberg falls. Gross violation of gait. Positive symptom of Babinsky on the left.

Biochemical blood test: glucose - 6.8 mmol / l; urea - 5.96 mmol / l; creatinine - 82 mmol / l; bilirubin - 11.83 mmol / l; cholesterol - 3.6 mmol / l (norm 3.3-6.2); LDL - 1.23 mmol / l; HDL - 1.29 mmol / l; triglycerides - 1.41 mmol / l; ALT - 109 units / l; ACT - 51 U / L; KA - 1.75; antistreptolysin O - 297 IU / ml; CRP - 2 mg / l; rheumatic factor - 8 IU / ml; potassium - 4.84 mmol / l; sodium - 142.4 mmol / l.

MRI of the brain: in the gray and white matter of the occipital lobe of the right hemisphere of the large brain, an area of an increased MR signal was detected in the mode of diffusion-weighted MP images. A small focus of the altered signal is visualized in the back leg of the inner capsule of the right hemisphere of the brain. MRI data correspond to "acute" heart attack and cavernoma in the right hemisphere of the large brain.

MP - angiography of cerebral vessels: blood flow in the right internal carotid artery is not visualized (occlusion). The blood flow in the right middle cerebral artery is determined in the initial section (in section M1), is sharply reduced, and is not further visualized. Blood flow is detected along the right posterior connective artery, along the right posterior cerebral artery, blood flow is traced to the initial section (in area P2), it is sharply reduced, and then it is not visualized. There is a decrease in the signal from blood flow in section A1 of the right anterior cerebral artery, signs of extended stenosis of the distal sections of the Ml portion of the left middle cerebral artery are detected. There is an asymmetry of the vertebral arteries (the left is wider than the right - 0.3 cm and 0.2 cm, respectively), a sharp decrease in the signal from blood flow is detected in the U4 section of the right vertebral artery after the posterior cerebellar artery has departed (hypoplasia). Blood flow through the posterior connective artery is visualized. The remaining vessels are without features. After systemic thrombolytic therapy, dynamics is noted in the form of a signal from the blood flow in the P2 area of the right posterior cerebral artery and an increase in blood flow in the A1 area of the right anterior cerebral artery.

Endocrinologist consultation - type 2 diabetes mellitus. Diabetic polyneuropathy.

Diagnosis: Acute cerebrovascular accident with the development of a heart attack in the pool of the right middle and posterior cerebral arteries. Atherosclerosis. Occlusion of the right internal carotid, middle cerebral, posterior cerebral arteries. Arterial hypertension. Type 2 diabetes. Diabetic polyneuropathy.

On the first day of the acute period of ischemic stroke, a study was conducted of the endothelial dysfunction markers of soluble adhesion molecules sICAM-1 and sVCAM-1, the expression level of which was - sICAM - 788.02 ng / ml and sVCAM - 732.26 ng / ml (see Fig. .four). The obtained data suggest an unfavorable course of ischemic stroke in this patient.

The patient in connection with the prognosis of an adverse course of ischemic stroke was prescribed complex intensive care. However, the patient's condition in the next days of the disease was assessed as moderate. On day 21 of the disease, a study of endothelial dysfunction markers - soluble adhesion molecules sICAM-1 and sVCAM-1, the expression level of which was - sICAM - 1159 ng / ml and sVCAM - 788.77 ng / ml) was again conducted. In the following days, this patient noted a slow regression of neurological symptoms. The patient needed constant monitoring of his condition and intensive care due to the threat of possible complications, since high MA sICAM-1 and sVCAM-1 indices indicated activation of hemostasis.

Example 3

Patient Ch., 72 years old, was admitted with complaints of speech impairment and weakness in the right limbs.

In the history of a long time, he suffers from a constant tachysystolic form of atrial fibrillation, arterial hypertension, type 2 diabetes. He fell ill sharply, speech was disturbed, and growing weakness appeared in the right limbs.

Objectively: a serious condition. The skin is of normal color. Lymph nodes are not enlarged. NPV 17 per minute. Heart sounds are muffled, rhythmic, heart rate of 75 per minute, the rhythm is incorrect, satisfactory filling and tension. HELL 150/70 mm Hg The abdomen on palpation is soft, painless. The symptom of lumbar effusion is negative on both sides. Pelvic function controls.

Neurological status: Doubt. Follows simple instructions, but quickly depletes. Symptom Kernig with 2 stor. Eye slots, pupils equal, eyeball movements and full. Horizontal fine nystagmus. The face is symmetrical. Swallowing is broken. Reflexes from the soft palate and posterior pharyngeal wall are not caused. Lockjaw. Raises the left hand, bends and extends in the elbow joint, bends the fingers. Raises the left leg to 40 degrees; holds and extends in the knee joint, possibly dorsiflexion of the left foot. The tone of the left limbs is increased but spastic type. Right hemiplegia with low muscle tone. Tendon reflexes are symmetrical. Symptom of Babinsky from two sides. Reflexes of oral automatism. Anartria.

Biochemical analysis of blood: glucose - 6.9 mmol / L, urea - 9.83 mmol / L, bilirubin - 10.11 μmol / L, cholesterol - 5.5 mmol / L, ACT - 21 I / L, ALT - 11 I / l, creatinine - 110 μmol / l, alkaline phosphatase - 83.78 U / l.

MPT of the brain: acute heart attack in the area of the bridge. Post-infarction changes in the right hemisphere of the large brain. Changes in both hemispheres of the cerebrum and in the right hemisphere of the cerebellum according to the type of discirculatory encephalopathy.

MP - angiography of cerebral vessels: lack of signal from the basilar artery, decreased blood flow in the right posterior cerebral artery. Rear trifurcation on the left.

Diagnosis: Acute cerebrovascular accident with the development of a heart attack in the vertebro-basilar system on the background of atherosclerosis, arterial hypertension, a constant form of atrial fibrillation, type 2 diabetes.

On the first day of the acute period of ischemic stroke, we studied the endothelial dysfunction markers of soluble adhesion molecules sICAM-1 and sVCAM-1, the expression level of which was sICAM-1211.0 ng / ml and sVCAM-951.32 ng / ml (see Fig. .5). The obtained data suggest an unfavorable course of ischemic stroke in this patient.

A patient is prescribed medication in connection with the prognosis of an adverse course of ischemic stroke. However, the patient's condition in the following days of the disease was assessed as severe. On the 21st day from the beginning of the acute period, the study of endothelial dysfunction markers - soluble adhesion molecules sICAM-1 and sVCAM-1, the expression level of which was - sICAM-1 - 1211 ng / ml and sVCAM-1 - 1479 ng / ml, was again conducted. On admission, on the first day of an ischemic stroke, the severity of the disease was evaluated at 16 points on the NIHSS scale. The level of the studied MA spectrum (sICAM-1 and sVCAM-1) exceeded the initially high rates. By day 21, despite intensive therapeutic measures, the patient showed an increase in the degree of neurological disorders, the severity of which corresponded to 20 points on the NIHSS scale. In the following days, the patient's condition gradually worsened, the patient was transferred to the intensive care unit. In the future, a fatal outcome occurred.

Thus, the analysis of immunological markers of inflammation in patients with ischemic stroke both in the group as a whole and in individual patients showed that changes in their level correlate with the severity of the dynamics of neurological disorders with high sensitivity, specificity and accuracy of prognosis in the first days of the acute period of ischemic stroke in this category of patients.

Claims (1)

A method for predicting the course of ischemic stroke in patients with diabetes mellitus, including sampling an analyzed blood sample, characterized in that a cytofluorimetric analysis of the obtained test sample is carried out for the presence of endothelial dysfunction markers - soluble adhesion molecules sICAM-1 and sVCAM-1, the concentration of which is calculated by the calibration the graph of standard curves, and with the value of expression levels of adhesion molecules sICAM-1 591.9 ng / ml or more and sVCAM-1 632 ng / ml or more in the first days of the acute period of ischemic nsulta then save the data of the dynamics levels or increased levels relative to baseline for predicting adverse ischemic stroke in patients with diabetes.

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