RU2631745C1 - Method for prediction of functional restoration in patients with ischemic stroke - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: on day 2-5 of the ischemic stroke, 24-hour cardiorespiratory monitoring is performed, with an estimate of the number of apnea episodes during nighttime sleep. If 123 or less apnea episodes are recorded, post-stroke functional recovery is predicted as favorable, and at a value of more than 123 - as unfavorable.

EFFECT: increased reliability of diagnosis, allows early detection of possible complications.

3 tbl, 2 ex

Description

The invention relates to medicine, in particular to neurology, and can be used to predict the restoration of neurological functions in the early post-stroke period.

Increasing the efficiency and further improving the neurorehabilitation system is an urgent task of angioneurology [Moris A.D., Grosset D.G., Squire I.B. et al. The experiences of an acute stroke unit: implication for multicentre acute stroke trials., J. Neurol. Neurosurg Psych., 1993; 56: 352-355]. Early rehabilitation, carried out in the acute period of a stroke (the first 3-4 weeks from the moment of its development), should create a basis that ensures the achievement of the maximum possible result at the next stages of treatment. In particular, if preventive treatment is not carried out at the early stages, the task of post-stationary rehabilitation services will become much more complicated, and in some cases it can be impossible [Gudkova VV, Stakhovskaya LV, Kirilchenko TD et al. Early rehabilitation after a stroke. Consilium medicum, 2005; 8: 692-696]. The results of the generalized experience show that the rate of restoration of neurological functions is highest in the early post-stroke period, which is explained by the onset of the functioning of neurons reversibly damaged during the primary lesion [Vorlow C.P., Dennis M.S., van Hein J. et al. Stroke. A practical guide for managing patients. St. Petersburg, 1998]. The resumption of the function of nerve cells in this case occurs due to an improvement in their blood supply, restoration of metabolism, and relief of cerebral edema. Therefore, the most important medical and social task is the maximum possible restoration of neurological functions in the early post-stroke period.

It is known that the rehabilitation process depends on many factors, such as age, severity of stroke, size and location of the ischemic focus, blood pressure level, the presence of anemia, coronary heart disease, atherosclerosis, atrial fibrillation, heart and kidney failure, diabetes mellitus, dyslipidemia, and also severe cognitive impairment and dementia (Saposnik G., Kapral M.K., Liu Y. et al., Investigators of the Registry of the Canadian Stroke Network, Stroke Outcomes Research Canada (SORCan) Working Group SO. Circulation 2011; 123: 739-49). The analysis of each risk factor separately significantly complicates the daily work of the doctor, does not give an objective idea of the prognosis, and significantly aggravates the individualization of post-stroke patient management.

Today, prediction of functional recovery in patients with ischemic stroke is known by examining biochemical parameters in blood serum (RU 2437099 from 12/20/2011; RU 2423711 from 07/10/2011) and anti-DNA research (RU 2195672 from 12/27/2002). However, these methods are time-consuming and do not have sufficient specificity to identify this condition.

There is also a method for predicting functional recovery in patients with ischemic stroke by determining fractional anisotropy (FA) and fractional anisotropy coefficient in the acute period of a stroke - on days 14-15 - using brain MRI in diffusion-tensor (DT) MPT mode (RU 2508048 from 08/27/2014). The disadvantages of the method are the high financial cost and the need for high-field MRI devices, which is difficult for widespread practice.

The closest technical solution to the claimed method is a method for predicting functional recovery in patients with ischemic stroke, while in a patient in the early recovery period after the first ischemic stroke, the degree of neurological deficit is assessed using the NIH-NTNDS stroke scale. The level of personal anxiety is determined on the Spilberger-Hanin scale and the serum content of neurotrophic factor (NGF). Calculate the regression rate of neurological disorders according to the mathematical formula based on the obtained values. Depending on the value of the calculation, a high or moderate probability of a favorable recovery of neurological functions is predicted or a negative result of the restoration of neurological functions after a stroke is predicted (RU 2569718 of 11/27/2015). The disadvantages of the method are the complexity and duration of the research procedure, among other things, not taking into account somatic factors affecting the prognosis.

The technical result consists in expanding the arsenal of technical means, in particular, methods for predicting functional recovery in patients by 2-5 days of ischemic stroke with high accuracy of the forecast.

The technical result is achieved by creating a method for predicting functional recovery in patients with ischemic stroke, which consists in examining the patient, while on the 2-5th day of ischemic stroke, cardiorespiratory monitoring is carried out with an estimate of the number of apnea episodes during night sleep, and with apnea value 123 and less post-stroke functional recovery is predicted as favorable, and with a value of more than 123 - as unfavorable.

The scientific result of the invention is to predict the degree of neurological recovery of patients depending on the number of episodes of apnea at night. If the amount of apnea exceeds 123, then patients have the worst recovery potential in terms of achieving functional independence.

A total of 56 patients with ischemic stroke were included in the study; Of these, 24 (43%) are men and 32 (57%) are women. The age of patients at the time of inclusion in the study ranged from 19 to 87 years, averaging 62 ± 15 years. Available in patients with cardiovascular disease are presented in table 1.

Acute cerebrovascular accident (stroke) with the formation of a heart attack in the left hemisphere of the brain was suffered by 26 (46%) patients, in the right - 24 (43%) and in the vertebral-basilar system - 6 (11%) patients. With the help of head MRI, a large-sized cerebral infarction was visualized in 19 (34%), medium-sized - in 10 (18%), and small-heart attack - in 27 (48%) patients. Cardioembolic stroke was verified in 19 (34%) patients, lacunar stroke in 16 (29%), atherothrombotic stroke in 14 (25%), stroke of unspecified genesis in 7 (12%) patients. Hemodynamically significant atherosclerosis of the brachiocephalic arteries (stenosis of more than 60% of the diameter of the artery) was detected by duplex scanning in 16 (28%) patients, hemodynamically insignificant in 38 (68%) patients.

The severity of neurological deficits was evaluated by the National Institutes of Health Stroke Scale (NIHSS), in which a score of 0 corresponds to the absence of neurological impairment, and 25 points to their maximum severity. Assessment of the daily activity of the patient’s functional state was carried out using the modified Rankin scale (mRS) [Vorlow, Ch. P., Dennis, M., van Gein, J. et al. Stroke. A practical guide for managing patients. St. Petersburg, 1998]. The absence of symptoms was rated at 0 points; minimal symptoms that do not limit daily activity - 1 point; some violations requiring limited assistance in some cases, while self-care was possible in full - 2 points; moderate decrease in activity, requiring outside help, but the patient can walk - 3 points; marked decrease in activity, requiring outside assistance - 4 points; bedriddenness requiring constant assistance - 5 points. The assessment was performed initially (during hospitalization of the patient, for 1-3 days), as well as after 2-3 weeks, against the background of rehabilitation measures.

The presence and structure of respiratory disorders in a dream was studied by the method of daily cardiorespiratory monitoring (CT-04-3P (M), Inkart, St. Petersburg). The study was carried out on 2-5 days from the onset of the disease. Registration of respiratory disorders was performed at night from 23.00 to 7.00. The analysis of respiratory disorders was carried out automatically and was supplemented by a visual expert assessment of each fragment. Registered: the total number of episodes of respiratory failure in a dream (VAT); Apnea episodes - a decrease in the flow rate of inspiration by 90% or more for 10 seconds or more during the entire episode; Apnea-hypopnea index (YAG) - the number of apnea / hypopnea per hour (Tsara V, Amfilochiou A., Papagrigorakis JM, et al. Guidelines for Diagnosing and Treating Sleep related Breathing Disorders in Adults and Children. Hippokratia. 2010; 14 (1) : 57-62).

Computer statistical processing of the results was carried out on the basis of the STATISTICA 7.0 software package (StatSoft, USA). To determine the predictors of an adverse outcome, a comparison was made between two independent groups using the Mann-Whitney U-test and the Yeats-corrected chi-square test. A statistically significant result was considered at p <0.05. A discriminant analysis was performed to confirm the role of factors considered as predictors and to identify their contribution to the outcome. We calculated (according to the Woolf method) the odds ratio (OR) and the 95% confidence interval (95% CI) of the OR for the occurrence of an unfavorable outcome (O. Rebrova, Statistical Analysis of Medical Data. M., Media Sphere, 2002).

During hospitalization - the initial - the severity of neurological deficit, as assessed by the Stroke Institutes of Health (NIHSS), ranged from 2 to 18 points, the median was 6 (4; 10) points. Assessment of daily activity - the functional state - of the patient was carried out using a modified Rankin scale (mRS). The score ranged from 1 to 5, the median - 3 (2; 5).

After 2-3 weeks, against the background of rehabilitation measures, various dynamics of neurological disorders were noted. When re-evaluating, the average score for NIHSS was 3 (1.5; 5), for mRS - 1 (0; 3). Depending on the degree of achieved functional independence, the patients were divided into 2 groups: group 1 (n = 40) - daily activity score of 2 or less points according to mRS (functionally independent); Group 2 (n = 16) - score of 3 or more points for mRS (need assistance / care). The groups were comparable by age, gender, localization and pathogenetic subtype of stroke, severity of occlusive atherosclerosis of the vessels of the head, and the frequency of cardiac pathology (table 2). At the same time, the groups initially differed in the severity of neurological deficit, the severity of respiratory disorders (see table 2), as well as in the magnitude of cerebral infarction - large and medium foci more often occurred in group 2: 12/16 (75%) compared 12/40 (30%) in the 1st group of patients (p = 0.01).

It is obvious that the influence of prognostic factors can in some cases be combined and overlap while they are present in one patient. Therefore, in order to confirm the role of factors considered as predictors of an unfavorable functional outcome, and to identify their specific contribution to the outcome, a discriminant analysis was performed (table 3).

The prognostic significance of the studied model as a whole with respect to the early functional recovery of patients was established. Moreover, among all the studied factors, only the number of apnea episodes during night sleep demonstrated its own significance as a predictor of an unfavorable prognosis (see table 3).

To determine the magnitude of the apnea indicator associated with an unfavorable prognosis regarding the restoration of daily functional activity after ischemic stroke, the absolute values of the medians and 25- and 75-percentiles in the compared groups were compared. It was established that the amount of apnea at night more than 123 is associated with the worst functional recovery (chi-square with Yates correction, p = 0.005); OR 7.5 (95% CI 4.99-11.31).

Thus, an increase in the number of apnea episodes at night over 123 is an independent prognostic factor of unfavorable functional recovery in the early stages (the first 3 weeks) after an ischemic stroke. This indicator characterizes the severity of respiratory disorders, the presence of which adversely affects the processes of neuroplasticity and limits the possibility of restoring the neurological functions and daily activity of the patient. The prognostic value of nocturnal apnea persists after adjusting for other prognostic factors, i.e. is an independent predictor of adverse restoration of functional activity after ischemic stroke.

The method was carried out as follows.

All patients on the 2-5th day of ischemic stroke underwent daily cardiorespiratory monitoring with an estimate of the number of apnea episodes during night sleep. With an apnea value of 123 or less, the prognosis of early post-stroke functional recovery was considered favorable. With apnea greater than 123, an unfavorable prognosis of an early restoration of daily activity (functional independence) was determined. In this case, intensification of therapy was carried out for the timely correction of respiratory disorders. Thus, the use of the indicator of apnea episodes during night sleep as a predictor of early functional recovery after ischemic stroke can be promising for the personification of rehabilitation measures and improving the patient's quality of life.

Method implementation examples

Example 1

Patient M., 77 years old, suffered an ischemic stroke with the formation of a large heart attack in the basin of the left middle cerebral artery due to cardiogenic embolism against the background of atrial fibrillation. At admission, the severity of neurological disorders corresponded to a severe degree (mRS 5 points) - the patient needed outside care. Registered: the total number of episodes of respiratory failure in a dream (VAT); Apnea episodes - a decrease in the inspiratory flow rate of 90% or more for 10 seconds or more during the entire episode. With cardiorespiratory monitoring on the 3rd day from the debut of the disease, 60 episodes of apnea were recorded during night sleep (from 23.00 to 7.00). After 3 weeks, a significant improvement in neurological functions and the restoration of functional independence in everyday life (mRS 1 point) were noted.

Example 2

Patient S., 73 years old, suffered an ischemic stroke with the formation of a large stroke in the basin of the right middle cerebral artery due to cardiogenic embolism against the background of atrial fibrillation. At admission, there was a pronounced neurological deficit, a pronounced limitation of daily activity (mRS 5 points) - the patient needed outside care. Registered: the total number of episodes of respiratory failure in a dream (VAT); Apnea episodes - a decrease in the inspiratory flow rate of 90% or more for 10 seconds or more during the entire episode. During cardiorespiratory monitoring, 157 episodes of apnea were recorded during night sleep (from 23.00 to 7.00). After 3 weeks, a pronounced neurological deficit and a pronounced limitation of functionality (mRS 4 points) persisted, the patient needs outside care.

Thus, the claimed invention provides already at an early stage for 2-5 days of ischemic stroke the ability to predict functional recovery in patients with high accuracy, and also expands the arsenal of technical means used to predict this condition.

Claims (1)

A method for predicting functional recovery in patients with ischemic stroke, which consists in examining a patient, characterized in that daily cardiorespiratory monitoring is carried out on the 2-5th day of ischemic stroke with an estimate of the number of apnea episodes during night sleep and, with apnea value of 123 or less, post-stroke functional recovery is predicted as favorable, and with a value of more than 123 - as unfavorable.