RU2723758C1 - Method for early prediction of intracranial hypertension in patients with craniocerebral injury - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to ultrasonic diagnostics, neurosurgery, anaesthesiology and resuscitation. For prediction of intracranial hypertension (ICT) in patients with craniocerebral injury, ultrasonography of the optic nerve is carried out daily from the onset of disease for 3–7 days. During the examination, diameter of external vagina of optic nerve (DEVON) is measured at the junction of the outer shell of the eyeball in the dura mater surrounding the optic nerve. Procedure is carried out daily, 3–4 times on both eyes, calculating for each eye an arithmetic average value from these measurements. Simultaneously with ultrasonic examination of the optic nerve, a pulsation index (PI) is measured along the middle cerebral artery. On the basis of obtained DEVON numbers and PI the Y value is calculated by formula: Y = -17 + 2.56 × DEVON + 1.14 × PI. If the value of Y is found to increase from the initial positive value or if the negative value of Y is changed to positive, an ICT is predicted.EFFECT: method enables obtaining reliable data on the prediction of ICT in patients with craniocerebral injury using non-invasive studies with a questionable result in favour of ICT, which enables to make an adequate decision on the tactics of surgical management.1 cl, 3 dwg, 3 tbl, 3 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to ultrasound diagnostics, neurosurgery, anesthesiology and resuscitation, and can be used to predict intracranial hypertension (ICH) in adult patients with traumatic brain injury (TBI).

State of the art

Intracranial hypertension is considered a persistent increase in intracranial pressure (ICP) up to 20 mm RT. Art. and more, lasting at least 5 minutes. ICH is a frequent and formidable complication that occurs in patients with traumatic brain damage, significantly worsens the prognosis of the course of the disease. According to various studies in patients with severe TBI, a persistent increase in ICP is accompanied by an increase in mortality of up to 92% [Rosner M.J., Becker D.P. ICP monitoring: complications and associated factors. Clin. Neurosurg. 1976; 23: 494-519. PMID: 975699]. One of the main tasks of intensive care for patients with intracranial hemorrhage is the timely correction of ICH, for which the early (up to five days) detection of an increase in intracranial pressure after a traumatic brain injury is relevant.

A known method of invasive monitoring of ICP level by installing sensors and systems in the ventricles or brain substance. Its advantages include the accuracy and continuity of ICP recording [Bratton S.L., Chesnut R.M., Ghajar J. et al. Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitorering. J Neurotrauma. 2007; 24 Suppl 1: S37-S44]. However, a significant drawback of this method is its invasiveness, which leads to an increased risk of developing infectious and hemorrhagic complications. Intracranial pressure sensors are expensive and are installed intraoperatively, therefore, value is lost in the selection of patients for surgical intervention and determining the concept of their further treatment.

A known method of non-invasive monitoring of ICP using a pulsation index (PI), measured using transcranial duplex scanning (TKDS) [Trukhanov SA, Stulin ID, Krylov VV, Levchenko OV, Znayko G. G. Transcranial dopplerography in combination with echopulsography and in the assessment of intracranial and cerebral pulsation pressure in patients with intracranial hemorrhage. Journal of Neurology and Psychiatry 7, 2014, pp. 37-42]. The pulsation index is calculated by the formula: (LSC system. - LSC diast.) / LSC medium., Where LSC system. - linear systolic blood flow velocity, LSC diast. - linear velocity of blood flow diastolic, LSK environments. - average linear blood flow velocity. Normal PI values range from 0.8-0.9. With an increase in ICP, there is a decrease in LSC diast., An increase in the systolic-diastolic difference in LSC and, as a result, an increase in the pulsation index. With a sensitivity of 76% and a specificity of 72% for the threshold PI value, a value of 0.9 is proposed to be used as a predictor of ICH. However, the calculation of ICP only on the basis of the use of the pulsation index gives very significant errors, because its various physiological and pathological conditions [Bellner J, Romner B, Reinstrup P, Kristiansson K-A, Ryding E, Brandt L: Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol 62: 45-51, 2004; Prunet B, Asencio Y, Lacroix G et al. Noninvasive detection of elevated intracranial pressure using a portable ultrasound system. Am J Emerg Med. 2012; 30: 936-941]. A significant drawback of this method of measuring intracranial pressure is the dependence of PI on blood pressure, heart rate, cerebral perfusion pressure, concentration of carbon dioxide in the blood, level of consciousness, microangiopathy in diabetes mellitus, cerebral resistance and large vessel compliance [Markwalder TM, Grolimund P, Seiler RW et al. Dependency of blood flow velocity in the middle cerebral artery on end-tidal carbon dioxide partial pressure - a transcranial ultrasound Doppler study. J Cereb Blood flow Metab. 1984; 4: 368-372]. In this connection, it is not advisable to rely only on the value of PI according to the TKDS.

In the prior art, ultrasound methods for diagnosing ICH are known by means of ultrasound examination of the optic nerve (USN), which can serve as an additional, non-invasive, repeatedly repeated, relatively cheap study that allows you to evaluate the dynamics of ICP and its growth to critical values (Tayal VS, Neulander M., Norton HJ et al. Emergency department sonographic measurement of optic nerve sheath diameter to detect findings of increased intracranial pressure in adult head injury patients. Ann. Emerg. Med. 2007; 49 (4): 508-514. DOI: 10.1016 / j. annemergmed.2006.06.040; Rajajee V., Vanaman M., Fletcher JJ, Jacobs TL Optic Nerve Ultrasound for the Detection of Raised Intracranial Pressure. Neurocrit Care. 2011; 15 (3): 506-515. DOI: 10.1007 / s12028- 011-9606-8 .;). The optic nerve is surrounded by soft and arachnoid meninges (forming the inner vagina of the optic nerve), on top of which there is a subarachnoid space filled with cerebrospinal fluid, and the dura mater, which is the external vagina of the optic nerve. In the above studies, it was shown that an increase in ICP is transmitted to the subarachnoid space around the optic nerve and causes an expansion of the space in which the cerebrospinal fluid is located (that is, the diameter of the external sheath of the optic nerve (DNVN) expands, which can give an idea of the dynamics of growth or regression of ICH However, when conducting studies related to changing the NDVN, it was found that the measurement accuracy depends on the method of ultrasound, for example, the result of an inadequately selected U3-scan plane is to obtain erroneous NDVN values that do not allow adequate diagnosis of ICH.

This problem is solved by the ultrasonic method for diagnosing ICH (Petrikov S.S., Andreitseva M.I., Khamidova L.T., Solodov A.A. Diagnosis of intracranial hypertension using ultrasound examination of the optic nerve canal in patients with intracranial hemorrhage. Medical imaging. 2018; (3): 6-16. Doi.org/10.24835/1607-0763-2018-3-6-16), which is the closest to the claimed solution. According to this method, when conducting an ultrasound scan of the eye, a contact gel for U3 studies is applied to the anterolateral surface of the closed upper eyelid, the scan plane is removed behind the eyeball for visualization in the central part of the U3 image of the eye, lens and retina. To visualize the vertical course of the ophthalmic artery (and, accordingly, the vertical course of ST), the color Doppler mapping mode is used. The study includes measuring the diameter of the optic nerve (DZN) and the diameter of the external sheath of the optic nerve. Between ZN and its membrane there is a subarachnoid space with cerebrospinal fluid. With an increase in ICP, this space expands, that is, the expansion of the NDVN. Both of these parameters were measured at a distance of 3 mm behind the retina using an electronic meter as a perpendicular to the axial projection in two planes (vertical and horizontal). Measurements were repeated 3-4 times in both eyes. The arithmetic mean value from these measurements was considered as the value of DZN and DNVZN. To correctly determine the direction of the optic nerve, the color Doppler mapping was used to visualize the ocular artery (the acoustic power and mechanical index settings were the same as in the B-mode). If the course of the artery did not go in a strictly vertical position and the hypoechoic shadow from the trellis was visualized (in the case of active movement of the eyeballs), then such measurements were not taken into account. Based on the results of the studies, the following results were obtained: the normal values of NDVN in healthy volunteers were 4.8 ± 0.25 mm, and DZD was 2.4 ± 0.12 mm. An increase in DNVZN from 5.9 mm or more is an ultrasound sign of an increase in ICP above a threshold value (20 mm Hg or more).

However, the results obtained by ultrasound are variable, since this method is operator-dependent and requires exact observance of the research technique. When implementing this method, many researchers obtained various data on the threshold value of NDVN corresponding to an ICP value of 20 mm Hg. Art. and more. In addition, the measurement of NDVN at a distance of 3.0 mm behind the retina can also introduce errors in the diagnosis of ICH associated with the constitutional features of the studied patients. In particular, in slender and obese patients, the expansion of the subarachnoid space with cerebrospinal fluid between the CN and the external sheath of the optic nerve with an increase in ICP does not always occur at a distance of 3.0 mm behind the retina.

In this connection, in order to ensure accuracy and to speed up the research process, the claimed solution proposes to measure NDVN at the junction of the outer shell of the eyeball into the dura mater surrounding the optic nerve (at the bend, see Fig. 1). Also important in the claimed solution is the daily measurement of NDVN to determine the dynamics of changes in this indicator in the first five days after the head injury, and in the case of an increase in the data by 30% from the original, we can talk about the appearance of signs of ICH.

The technical problem solved by the present invention is to obtain reliable predictive data of intracranial hypertension in patients with traumatic brain injury using non-invasive studies conducted in the first five days with a dubious result in favor of ICH, allowing an adequate decision on the tactics of surgical treatment.

Disclosure of invention

Achievable technical result is to increase the reliability of predictive estimates of the occurrence of ICH due to the assessment of a set of indicators that allow to assess the dynamics of the increase or regression of increased ICP. The inventive method is characterized by a higher accuracy of forecasting in comparison with the prototype method.

The technical result is achieved by implementing the method for early prediction of intracranial hypertension in patients with traumatic brain injury, including performing an ultrasound examination of the optic nerve, according to which, the study is carried out in dynamics daily from the moment the disease begins

during 3-7 days, preferably within 5 days, during the study at the place of transition of the outer shell of the eyeball into the dura mater surrounding the optic nerve, the diameter of the external vagina of the optic nerve is measured, DNVD is measured repeatedly, calculating the arithmetic mean for each eye value from these measurements; simultaneously with an ultrasound examination of the optic nerve, the pulsation index is measured along the middle cerebral artery, on the basis of the obtained values of DNVZD and PI, Y is calculated by the formula: Y = -17 + 2.56 × DNVZN + 1.14 × PI, and if a daily increase in the value is detected Y for at least 3 days from the initial positive value (measured on the first day), or when detecting a change in the negative value of Y to positive, intracranial hypertension is predicted.

Distinctive from the closest solution are the signs that characterize the removal and measurement of DNVN in the place of transition of the outer shell of the eyeball to the dura mater of the optic nerve, in combination with the measurement of PI and the calculation of the forecast according to the formula taking into account the daily dynamics.

Brief Description of the Drawings

The invention is illustrated by drawings, where in FIG. Figure 1 shows ultrasound imaging of STs strictly vertically. Measurement of DNVZN in the place of transition of the outer shell of the eyeball to the dura mater ZN; in FIG. Figure 2 shows the ROC analysis curve for NDVN for ICP ≥20 mmHg. Art. The area under the curve (Area Under Curve, AUC) reflects the diagnostic accuracy of measuring the NDVN in predicting ICH; in FIG. 3 is a graph showing the dependence of the ICP value on the PI and NDVN factors processed by the SVM method (Support vector machines); the designations of squares and triangles are the parameters of a particular patient within 7 days of monitoring ICP (PI and NDVZN). So, the triangles correspond to an ICP value of 20 mm Hg. Art. and more, squares - ICP less than 20 mm RT. Art. Based on the calculation of PI and NDVN data at different ICP levels, 53 patients received the necessary data for early non-invasive prediction of ICH using ultrasound.

The positions in the figures denote: 1 - DNVZN (distance between the dura mater ZN), 2 - the outer shell of the eyeball, 3 - the bending point for measuring DNVZN, 4 - the trunk of the optic nerve, 5 - subarachnoid space ZN with cerebrospinal fluid located between the dura mater sheath ZN and soft with arachnoid.

The implementation of the invention

A method for early detection of ICP after a head injury involves performing an ultrasound of the optic nerve with the measurement of NDVN and the measurement of PI in TCD.

An ultrasound examination is performed in patients in dynamics daily for 3-7 days from the time of admission (in the first 24 hours from the onset of the disease) or the onset of the disease.

When conducting ultrasound scans, a linear sensor with a frequency of 7.5-14 MHz is used, the program is “surface”, the ultrasonic focus is placed on the retrobulbar space, the scanning depth is 4 cm. The acoustic power of the device is reduced to a minimum (about 25-30%) to prevent damage lens, thermal and mechanical indices are set to less than 1.0 to prevent local thermal effects on tissues (preferably 0.2-0.4).

On the anterolateral surface of the closed upper eyelid, a contact gel is applied for ultrasound studies. Slightly tilting, swaying and slightly turning the sensor 20-30 degrees clockwise and counterclockwise, they find the scanning plane behind the eyeball so that the optic nerve and retina are fully visible in the central part of the image.

To determine the correct direction of the optic nerve, the color Doppler mapping mode is used to visualize the ocular artery, which runs parallel to the optic nerve (the acoustic power and mechanical index settings should be the same as in B - mode).

In the obtained scanning plane, on which the outer shell of the eyeball, the optic trunk and the dura mater surrounding it are identified. At the place of transition (bending) of the outer shell of the eyeball into the dura mater surrounding the optic nerve, the NDVN is measured using an electronic meter as a perpendicular to the axial projection. Measurements during the study are repeated 3-4 times in both eyes. The magnitude of DZN and DNVZN consider the arithmetic mean value from these measurements. Since all measurements fluctuate within 1 mm, therefore, a very important aspect is the observance of all the nuances (identification of a vertically extending ocular artery) of the method of performing an ultrasound of the optic nerve.

Based on the results of the ROC analysis, the threshold value of the optic nerve sheath diameter was calculated at an ICP of 20 mm Hg. Art. and more than 5.9 mm (Fig. 2) with a sensitivity of 82%, a specificity of 70%. A fundamentally important point in this work is the daily dynamic performance of an ultrasound scan of ZN within 5-7 days from the moment of injury. Simultaneously with the measurement of DNVN, a second parameter is measured - the pulsation index of the middle cerebral artery (SMA), which can be implemented, for example, using well-known methods TKDS [Khamidova Lail Timarbekovna. Dopplerographic assessment of cerebral hemodynamics in patients with ruptured arterial aneurysms of the brain: abstract of the dissertation of the candidate of medical sciences: 01/14/13 / Khamidova Laylay Timarbekovna; Moscow, 2012. - 25 s].

Based on the obtained values of NDVN and PI, measured at the time of admission of the victim and then in dynamics for at least 5 days, calculate the ICP index (Y) according to the formula:

Y = -17 + 2.56 × DNVZN + 1.14 × PI,

where Y is an indicator having a specific value obtained from the results of measurements of the NDVN and PI, which can have both positive and negative values. The farther the value of Y lags from 0, the more confident the forecast.

According to the results of the study, each day they get their Y value. By the nature of the change in Y, a forecast is made about the increase or regression of ICH. For example, when each subsequent value of Y increases from the initial measured positive value, and also when the negative value of Y changes to positive, an increase in ICP is predicted, and the further the value of Y is from zero to the positive side, the more pronounced the ICF will be. The decision on the tactics of intensive care and on the need for surgical treatment is taken when the growth of the Y indicator (including daily measurement) is detected and its value is exceeded by more than 30% compared with the initial value measured on the first day.

At the Research Institute of the Joint Venture named after N.V. Sklifosovsky examined 53 patients with a head injury and implanted ICP sensors, who underwent dynamic ultrasound of ZN and TKDS for 7 days from injury. Based on the calculation of PI and NDVN data at different ICP levels in 53 patients, the formula was obtained using SVM for early non-invasive prediction of ICH using ultrasound in the first 7 days after the injury. It should be noted that since the values of PI and NDVN were compared with the data of direct monitoring of intracranial pressure, not always a single value of NDVN of 5.9 mm in a particular patient corresponded to an intracranial pressure of 20 mm Hg. Art. and more. As a result of the studies, it was concluded that it is necessary to measure two hemodynamic parameters by ultrasonic methods.

Below are examples of specific implementations of the proposed method for early prediction of intracranial hypertension in patients with traumatic brain injury by increasing intracranial pressure.

Example 1. Patient P., 37 years old, diagnosis: Closed craniocerebral injury, wakefulness level according to GCS 7 points. On admission, an ultrasound of the optic nerves was performed (the average NDVN value was 5.3 mm) and TKDS (PI = 0.7). When taking into account the initial data in the formula Y = -2.634, therefore, Y has a negative value, is located far from "0", an increase in% of the value of Y was not observed in a daily study. It was concluded that with such data, DNVZN and PI ICP <20 mm Hg. Art. This fact was confirmed by ICP measurement by an implanted ICP sensor.

Example 2. Patient M., 42 years old, diagnosis: Closed craniocerebral trauma, wakefulness level according to GCS 8 points. On admission, an ultrasound of the optic nerves was performed (the average NDVN value was 6.4 mm) and TKDS (PI = 1.6). When taking into account the initial data in the formula Y = 1.21, therefore, Y has a positive sign, it was concluded that for such values of DNVZN and PI ICP> 20 mm Hg. Art. The patient was operated on in the first day after the injury in the volume of decompressive craniotomy, removal of the subdural hematoma in a volume of 100 cm3. The next day, dynamic monitoring of ICH was carried out. According to the value of Y on the 2nd day, we can talk about the absence of signs of ICH (Y = -0.158).

Example 3. Patient G., 31 years old, diagnosis: Closed craniocerebral injury, wakefulness level according to GCS 7-8 points. On admission, an ultrasound of the optic nerves was performed (the average NDVN value was 5.9 mm) and TKDS (PI = 0.8). When taking into account the initial data in the formula Y = -0.984, therefore, Y has a negative value, it was concluded that at such values, the DNVZN and PI ICP will be less than 20 mm Hg. Art. But, since the obtained value of Y is located close to 0, it was therefore recommended that dynamic repeated ultrasounds be performed to detect an increase or regression of the ICP. On the 2nd day after the injury, Y = -0.3, but the value is located close to "0". In this regard, the patient was continued intensive care in the ICU without surgical intervention. On the 3rd day after the injury, the value Y = 0.07; as a result, data were obtained that characterize the initial signs of ICH. The patient underwent surgery. In the dynamics of the combination of ultrasound methods, there was a regression of the revealed signs of increased ICP.

In patients without implanted sensors, the use of the claimed invention allows one to register a tendency to increase ICH, which will affect the management of patients with traumatic brain injuries (intensification of therapy and / or surgical treatment). In hospitals where there is no possibility of invasive monitoring of intracranial pressure, ultrasound examinations of ZN and TKDS can serve as a method of choice in the diagnosis and monitoring of intracranial pressure.

Claims (7)

A method for early prediction of intracranial hypertension in patients with traumatic brain injury, comprising performing an ultrasound examination of the optic nerve, characterized in that the study is carried out in dynamics daily from the onset of the disease for 3-7 days, during the study, at the point of transition of the outer shell of the eyeball into the dura mater surrounding the optic nerve, the diameter of the external vagina of the optic nerve (NDVN) is measured, the NDVN is measured daily, 3-4 times in both eyes, calculating the arithmetic mean value for each eye from these measurements, simultaneously with an ultrasound examination of the optic nerve, a pulsation index (PI) is measured in the middle cerebral artery, based on the obtained values of the DNVZD and PI, the Y index is calculated by the formula: Y = -17 + 2.56 × DNVZN + 1.14 × PI, if an increase in the Y value from the initial positive value is detected or when the negative Y value changes to positive, intracranial hypertension is predicted.

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