RU2629019C1 - Method of intraoperative warning of local ischemic damage to brain at microsurgeric operation on cerebral arterial aneurysis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for intraoperative prevention of local ischemic brain damage during microsurgical surgery for cerebral arterial aneurysms, anesthesia, intraoperative therapy, with preventive temporary cloning of an aneurysm and an intravenous drip of cytol flavin are performed. At the stage of surgical access to the aneurysm, the preparation of cytoflavin is injected intravenously in drops of 10 ml in dilution with 200 ml of physiological solution for 30 minutes. In this case, a temporary clip with short intervals of vessel occlusion is applied to the feeding aneurysm of the artery.

EFFECT: invention makes it possible to reduce the occurrence of complications during clipping of an aneurysm, to increase the tolerance of occlusion of the artery and to reduce the recovery postoperative period.

1 tbl, 1 ex

Description

The invention relates to the field of neurosurgery, and in particular to a method of intraoperative prevention of local ischemic brain damage during microsurgical surgery for cerebral arterial aneurysm with preventive temporary clipping and the introduction of an intravenous drip of the drug cytoflavin.

Known use of the drug cytoflavin in ophthalmology for the prevention and treatment of postoperative patients, RU No. 2464000 C1, A61F 9/008, A61K 38/04, A61K 38/05, 10/20/2012; RU No. 2462280 C1, A61N 1/20, A61K 31/194, A61K 31/455, 09/27/2012; RU No. 2310424 C1, A61F 9/00, A61N 1/32, A61K 31/194, A61K 31/525, 11/20/2007.

It is known to use the drug cytoflavin in gynecology as a drug therapy in the treatment of inflammatory diseases, RU No. 2499594 C1, A61K 31/194, A61P 15/00, 11/27/2013; RU No. 2445058 C1, A61G 10/02, A61K 31/167, A61K 31/194, A61K 31/405, 03.20.2012; RU No. 2391104 C1, A61K 31/525, A61K 31/522, A61K 31/375, A61K 31/355, 06/10/2010; RU No. 2348399 C1, A61K 31/02, A61K 31/525, A61K 31/455, 03/10/2009.

The use of the drug cytoflavin in dermatology is known for the complex treatment of oral or intravenous drip, RU No. 2573986 C1, A61K 31/194, A61K 31/455, A61K 31/525, A61N 1/32, 01/27/2016; RU No. 2444353 C2, A61K 31/194, A61K 31/196, A61K 31/43, A61K 31/455, 03/10/2012; RU No. 2436574 C2, A61K 31/194, A61K 31/455, A61K 31/522, A61K 31/525, 12.20.2011; RU No. 2430721 C1, A61K 31/075, A61K 31/194, A61K 31/455, A61K 31/525, A61K 31/573, 10/10/2011.

A known method of treating patients with abusal headache, including daily administration of an intravenous drip of the drug cytoflavin, RU No. 2547565 C1, A61K 31/708, A61K 31/194, 04/10/2015.

A known method of relieving withdrawal symptoms in the treatment of drug addiction by administering a drop-wise preparation of metabolic action of cytoflavin from 5 to 10 procedures, RU No. 2302227 C2, A61H 39/00, A61K 33/00, A61K 31/485, A61K 31/194, 07/10/2007.

A known method of treating chronic prostatitis of category II and erectile dysfunction, including the use of antibiotics with the additional introduction of a drop of the drug cytoflavin, RU No. 2489143 C1, A61K 31/135, A61K 31/194, A61K 31/47, 08/10/2013.

A known method for the correction of cognitive dysfunctions and autonomic-sensory polyneuropathy in patients with vibrational disease, including spa treatment and drug therapy with the introduction of an intravenous drip of the drug cytoflavin daily for 10 days, RU No. 2461373 C1, A61K 31/194, A61K 31/455 , A61K 31/525, A61K 31/166, 09/20/2012.

A known method for the prevention of contrast-induced nephropathy in radiopaque studies, including the appointment of the drug (with antioxidant and cytoprotective properties) cytoflavin one tablet 3 times a day for 2-5 days before radiopaque studies, RU No. 2414896 C1, A61K 31/194, A61K 31/455, A61K 31/525, 03/27/2011.

A known method of treating patients with severe acute poisoning, including the introduction of the drug cytoflavin as part of general therapy, RU No. 2429826 C1, A61K 31/341, A61K 31/194, A61K 31/455, A61K 31/525, 09/27/2011; RU No. 2419448 C1, A61K 36/57, A61K 31/00, 05.27.2011.

A known method of complex infusion therapy in patients with hyperglycemic ketoacidotic diabetic coma by alternating administration of saline, salt-free and colloidal solutions, drug therapy with the transition to maintenance therapy with the introduction of the drug cytoflavin, RU No. 2323279 C2, A 31H 31/194, A61K A61K 33/14, 05.20.2008.

There is a method of complex treatment of vegetative-vascular dystonia and arterial hypertension, including conducting a patient with bitemporal exposure to a traveling alternating magnetic field with additional therapy with the introduction of the drug cytoflavin in physiological solution, RU No. 2537312 C1, A61H 2/04, A61H 1/00, 27.12. 2014.

A known method of treating patients with obliterating diseases of the arteries of the lower extremities, including the introduction of the drug cytoflavin, RU No. 2523412 C1, A61K 31/047, A61K 31/194, A61K 31/245, A61K 31/455, A61K 31/525, 07.20.2014; RU No. 2508097 C1, A61K 31/194, 02.27.2014.

The use of the drug cytoflavin is known as a means of reducing the overproduction of nitric oxide, RU No. 2342131 C2, A61K 31/194, A61K 31/708, A61K 31/525, 12/27/2008.

There is a method of rehabilitation of neurological disorders in children with neuroinfections, including complex therapy with additional administration of the drug cytoflavin intravenously from the first days of the disease, RU No. 2482843 C2, A61K 31/194, A61K 31/195, A61K 31/197, A61K 31/455 A61K 31/525, May 27, 2013.

There is a method of treating influenza and other flu-like diseases complicated by pneumonia, providing for the appointment of antibiotic therapy and the introduction of the drug interleukin-1, followed by intravenous drip of the drug cytoflavin once a day for four days, RU No. 2518277 C2, A61K31 / 194, A61K31 / 455 A61K31 / 525, 06/10/2014.

It is known to use the drug cytoflavin by interstitial injection of the neurometabolic drug cytoflavin as part of a mixture of medicinal substances for cancer patients, RU No. 2463045 C1, A61K 31/194, A61K 31/455, A61K 31/525, A61K 31/166, 10/10/2012.

A known method of preoperative correction of respiratory disorders in patients with colorectal cancer using the drug cytoflavin, RU No. 2526828 C1, A61K 31/194, A61K 31/7084, A61K 31/525, 08/27/2014.

A known method of combined general anesthesia for cancer patients, including blood sampling from the ulnar vein and the introduction of cytoflavin in a dose of 0.16 ± 0.02 ml / kg of mass, followed by intravenous drip administration to its patient immediately before the start of anesthesiology, RU No. 2479324 C2 , A61M 21/00, A61K 31/194, A61K 35/14, 04/20/2013.

In the analysis of known methods, the introduction of the drug cytoflavin during operations for cerebral arterial aneurysm with temporary clipping was not found.

A known method of treating occlusive lesions of the vertebral artery by applying a vascular anastomosis in order to prevent cerebrovascular accident during surgery, RU No. 2178675 C2, A61B 17/12, 12/20/2002; RU No. 2156114 C1, A61 B17 / 12, 09/20/2000; RU No. 2038050 C1, A61 B17 / 12, 06/27/1995.

A known method of remote temporary occlusion of cerebral vessels by applying an occlusive device to the cerebral vessel, RU No. 2201718 C2, A61B 17/12, 10.04.2003.

Preventive temporary clipping is known to reduce the frequency of intraoperative aneurysm ruptures by 2.5–7 times, and removable clips with low jaw pressure are used to perform cerebral aneurysm surgery, and one of the most significant risk factors for cerebral ischemia is the duration of temporary clipping arteries. In addition, the tolerance of arterial occlusion is individual in each patient, depending on age, severity of the condition, adequacy of collateral circulation, etc., and especially in patients with difficult allocation of aneurysm, it is necessary to use preventive temporary clipping, but according to the fractional technique with short intervals of artery occlusion , http://meduniver.com/Medical/Neurology/vremennoe_klipirovanie_arterii_mozga.html MedUniver.

The use of the drug cytoflavin in operations for lesions of the vessels of the brain was not found.

A known method of anesthesia benefits, including anesthesia, intraoperative therapy, the introduction of an intravenous drip of the drug cytoflavin in an amount of 10 ml in a dilution of 200 ml of physiological solution, RU No. 2436603 C1, A61K 31/194, 12/20/2011.

This technical solution is made as the closest analogue of the present invention.

The closest analogue method involves premedication, cerebrospinal anesthesia and intraoperative therapy, and the cytoflavin preparation is used as one of the components of premedication - 10 ml in a dilution of 200 ml of physiological saline by intravenous drip for 5 min, after which spinal anesthesia is performed.

The introduction of the drug cytoflavin as one of the components of premedication in the closest analogue method is due to the use of an anesthetic aid for the operative delivery of pregnant women with severe gestosis and is aimed not only at blocking nociceptive impulses and compensating for the bioenergetic needs of body cells, but also at preventing hypoxic-ischemic damage to the head brain.

In this case, the introduction of the drug cytoflavin in the closest analogue method is aimed not only at the prevention of lesions of the central nervous system in women with severe gestosis with surgical delivery, but also at reducing the frequency of the complicated course in postoperative delivery.

The present invention is based on the solution of the problem, which allows to reduce the occurrence of complications when clipping aneurysm, to extend the tolerance of arterial occlusion and to reduce the recovery postoperative period of the patient.

The technical result of the present invention is to reduce the risk of developing postoperative ischemia during aneurysm clipping, to expand the use depending on age, severity of the condition, blood circulation adequacy, to reduce the possibility of neurological deficit and time of postoperative awakening, observation in the intensive care unit and treatment in the neurosurgical department.

According to the invention, this problem is solved due to the fact that the method of intraoperative prevention of local ischemic brain damage during microsurgery for cerebral arterial aneurysm includes anesthesia, intraoperative therapy, the introduction of an intravenous drip of the drug cytoflavin in an amount of 10 ml in a dilution of 200 ml of saline.

A microsurgical operation is performed with preventive temporary clipping of the aneurysm and the cytoflavin preparation is introduced at the stage of surgical access to the aneurysm.

The introduction of the drug cytoflavin is carried out within 30 minutes.

A temporary clip with short intervals of vessel occlusion is applied to the artery feeding the aneurysm.

The applicant has not identified sources containing information about technical solutions identical to the present invention, which allows us to conclude that it meets the criterion of "novelty."

Due to the implementation of the distinguishing features of the invention (in conjunction with the features indicated in the restrictive part of the formula), important new properties of the object are achieved.

The introduction of the drug cytoflavin at the stage of surgical access to the aneurysm in an amount of 10 ml in a dilution of 200 ml of saline for 30 minutes reduces the risk of postoperative ischemia and reduces the recovery postoperative period of the patient (reduces the possibility of a neurological deficit and the time of postoperative awakening, observation in the intensive care unit and treatment in the neurosurgical department).

The application of a temporary clip to the aneurysm-feeding artery with short intervals of vessel occlusion extends the tolerance of artery occlusion.

The applicant is not aware of any publications that would contain information on the influence of the distinguishing features of the invention on the achieved technical result. In this regard, according to the applicant, it can be concluded that the claimed technical solution meets the criterion of "inventive step".

The present invention is carried out as follows.

A microsurgical operation is performed with preventive temporary clipping of the aneurysm, and at the stage of surgical access to the aneurysm, the drug cytoflavin is administered intravenously in an amount of 10 ml in a dilution of 200 ml of saline for 30 minutes. A temporary clip with short intervals of vessel occlusion is applied to the artery feeding the aneurysm.

The implementation of the method confirms the presented example.

Patient L., age 42 liters.

The diagnosis is basic: Aneurysm PSA and SAK.

Representation of the patient: Patient L. with a verified aneurysm of PSA and SAH has a history of surgical intervention in the amount of microsurgical clipping of the aneurysm.

Operation Planning: KPTCH. Microsurgical clipping of PSA aneurysm.

Patient L. was scheduled for surgery on 07.25.2016.

Operation start time: 10:20. End time of operation: 14:00. Anesthesia: endotracheal anesthesia.

At the stage of surgical access, the introduction of an intravenous drip of the drug cytoflavin in an amount of 10 ml in a dilution of 200 ml of physiological solution.

An arched incision of the scalp in the left frontotemporal region. Musculo-aponeurotic flap is turned to the face. Trepanation in the left frontotemporal region was made from 1 milling hole using a craniotome. In addition, the scales of the temporal and large wing of the sphenoid bones to the base are resected. TMT is of normal color, not strained, transmits a pulsation of the brain, hemmed on the periphery, opened with a U-shaped incision, the base of the sphenoid bone. The brain is a normal color, pulsating. Frontobasal approach to the right optic nerve and right ICA. The cisterns of the optic nerve, ICA, interstitial and chiasmal were opened. Pa1 was sequentially isolated from two sides, PSA.

The introduction of the drug cytoflavin intravenously for 30 minutes.

Aneurysm was detected in the PSA area. The expressed adhesive process is determined. The neck of the aneurysm is isolated from adhesions. With a triple temporary clipping of A1 of the anterior cerebral arteries on both sides for no more than 7 minutes, each aneurysm is clip-oned with 1 clip. No bleeding.

Revision of blood vessels - patency is not visually impaired. TMT is sutured tightly. The bone is laid in place and fixed by 2 craniofixes. The wound is sutured in layers tightly, alcohol aseptic dressing. Blood loss 100 ml.

The patient is awakened, extubated and transported to the intensive care unit on spontaneous breathing and stable hemodynamic parameters. I was in the intensive care unit with a diagnosis of “Aneurysm of the brain without a gap” 19 h 20 min. Date of receipt 07.25.2016, time of receipt 14:15. Date of discharge: 07.26.2016, time of discharge: 09:35.

During the observation in the intensive care unit, the patient's condition is stable. Hemodynamics and gas exchange are stable.

Neurological indicators:

Consciousness: clear

Pupils: D = S

Photoreactions: live

Eyeballs: Center

Face symmetry: without visible asymmetry, ptosis of the left eyelid

Convulsive syndrome: no

Speech: not broken

Swallowing: not broken

Paresis right hand: 5 points, left hand: 5 points, right leg: 5 points, left leg: 5 points

Meningeal signs: no

In satisfactory condition he was transferred to the neurosurgical department.

A patient underwent CT angiography of cerebral vessels on July 27, 2016 at 14:20.

In the area of surgical intervention, there were no signs of hemorrhagic contents.

The intracranial part of the internal carotid arteries, the anterior, middle and posterior cerebral arteries, vertebral and main arteries are contrasted; the contrast up to the distal branches is uniform, without defects.

The anterior and posterior connective arteries are not clearly visualized (the Willis circle is functionally open).

Aneurysm, AVM is not visualized. The main arteries of the brain are contrasted up to the distal branches.

The implementation of the method is also confirmed by the results presented in the Table "Conducting a microsurgical operation for cerebral arterial aneurysm with temporary clipping and the introduction of cytoflavin".

The table shows that in patients of one age group, weighed by other diseases of the cardiovascular system, with the introduction of the drug cytoflavin, the development of ischemia, based on a study of CT of the brain, was not found.

Neurological deficit in this group of patients is not confirmed and the recovery postoperative period is much less than in patients for whom cytoflavin was not administered. It should be borne in mind that the number of days spent in the surgical department after surgery is dictated for all patients by the timing of removal of sutures from the wound, bed-day standards.

The more sensitive difference between the groups is the nature of the awakening and the level of consciousness after the end of the operation.

In the proposed invention, “The method of intraoperative prevention of local ischemic damage to the brain during microsurgical surgery for cerebral arterial aneurysm” used known technologies of intraoperative capabilities in microsurgical operations, widely used in neurosurgery, and the practical use of the proposed method determines, according to the applicant, compliance with its criterion " industrial applicability. "

The proposed method allows you to:

- reduce the occurrence of complications when clipping aneurysm (risk of developing postoperative ischemia);

- expand the tolerance of arterial occlusion (the possibility of use depending on age, severity of the condition, and adequate blood circulation);

to reduce the recovery postoperative period of the patient while reducing the possibility of a neurological deficit;

- reduce the recovery postoperative period of the patient while reducing the time of postoperative awakening;

- reduce the recovery postoperative period of the patient with a reduction in follow-up in the intensive care unit;

- reduce the recovery postoperative period of the patient while reducing treatment in the neurosurgical department.

Claims (1)

A method for intraoperative prevention of local ischemic damage to the brain during microsurgical surgery for cerebral arterial aneurysm, including anesthesia, intraoperative therapy, the introduction of an intravenous drip of cytoflavin in an amount of 10 ml in a dilution of 200 ml of saline, characterized in that the microsurgery is performed with a preventive temporary by clipping aneurysms and the drug cytoflavin begin to be administered at the stage of surgical access to an ism, administration is performed for 30 minutes while feeding to impose temporary artery aneurysm clips with short intervals vessel occlusion.