RU2741018C1 - Method for increasing patient's consciousness level in vegetative state - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine and pharmaceutics, namely to a method for increasing patient's consciousness level in the vegetative state. Method involves stimulating vasculogenesis and neurogenesis and increasing the degree of vascularisation of the involved cerebral tissue by the therapeutic course of the Cellex® preparation in a certain dose, subcutaneously in the skin fold area of the deltoid muscle daily for 15 days.EFFECT: invention provides higher clinical effectiveness in cerebral lesions in vegetative patients, prevention of risk of complications in patients due to subcutaneous administration of the preparation, minimizing adverse reactions and avoiding undesirable phenomena.1 cl, 7 tbl, 3 ex

Description

The invention relates to medicine, namely to neurology, and concerns the treatment of patients in a vegetative state (VS) caused by brain damage (GM) of traumatic and non-traumatic genesis, in particular, the restoration of consciousness and other lost functions by stimulating neurogenesis.

State of the art

In conditions of severe damage to GM and pronounced structural and functional changes that have arisen after traumatic, non-traumatic, or anoxic damage, it becomes extremely important to enhance the metabolism of intact neurons, which leads to an increase in their functioning and stimulation of neurogenesis. The effectiveness of the treatment of GM lesions of traumatic and non-traumatic genesis is directly dependent on the degree of vascularization - the formation and proliferation of blood vessels, in particular capillaries, which leads to an improvement in metabolism in the affected tissues.

Today it is known that neuroprotective drugs modulate the processes of neurogenesis, synaptogenesis, neurotransmitter activation in patients who are in a prolonged unconscious state. These include, in particular, the use of known drugs - low molecular weight peptide hydrolysates of the pig brain (cerebrolysin), cattle cerebral cortex (cortexin), synthetic analogs of ultrastructural components of cell membranes (citicoline), deproteinized extract with low molecular weight peptides and nucleic acid derivatives)

In addition, the possibility of restoring damaged tissue by using a recombinant neurotrophin, such as a neurotrophic factor derived from glial cells (Methods for therapy of neurodegenerative disease of the brain US 2014057974), is actively being studied; the use of growth factors to stimulate the growth and activity of neuronal cells in the tissues of the cortex, such as BDNF, NT-4/5 and NT-3 (Methods for therapeutic use of brain derived neurotrophic factor in the entorhinal cortex US 2006222631); the use of a composition containing substance-P for the prevention or treatment of ischemic lesions of GM (An agent for stimulating mobilization of endothelial progenitor cells KR 20110017345); stem cell factors or a stem cell factor modulator (Neuronally expressed stem cell factor modulates angiogenesis and neural stem cell migration to areas of brain injury US 2006286117).

However, among the methods and / or preparations known to date, no stimulating angiogenesis and promoting vascularization of the affected tissues have been found in conditions of severe damage to the GM in patients who are in prolonged unconsciousness. In addition, all of the above drugs, recombinant factors, angiogenic lipids, Rspondin polypeptides and methods of their administration are associated with difficulties in their use, routes of administration (mainly intravenous or intrathecal route of administration, in order to achieve the maximum positive effect) or their low efficacy in patients in the sun.

At the same time, in the therapy of this category of patients, the method of administration of the drug is of particular importance - intramuscular, intravenous, intraarterial, intrathecal or subcutaneous. The most optimal way of drug administration in patients with persistent or permanent VS is the subcutaneous or intracutaneous route of administration. Consequently, there is an increasing need for the use of a drug that has high efficiency in low doses and the most effective concentration with the possibility of its administration by subcutaneous or intradermal injection, which has a neuroprotective, neuroreparative effect, stimulating growth factors, differentiation, signaling and receptor molecules that control the processes of neurogenesis, apoptosis and autophagy of embryonic nervous tissue of GM and having a vasculogenic effect.

The claimed invention is aimed at solving the problem of increasing the level of consciousness of patients in the VS.

The use of the proposed method in clinical practice allows achieving several technical (therapeutic) and economic results:

- increasing the effectiveness of treatment of GM lesions of traumatic and non-traumatic genesis in patients in the VS, as well as ensuring positive dynamics of objective neurological and clinical indicators due to the use of Cellex®;

- prevention of the risk of complications in patients who have been unconscious for a long time due to subcutaneous administration of Cellex®, as opposed to intramuscular administration;

- minimization of side reactions and the almost complete absence of adverse events associated with taking Cellex®, by reducing the minimum effective doses in comparison with doses of analog drugs comparable to doses of peptide-amino acid parenteral nutrition.

The specified technical and therapeutic results in the implementation of the invention are achieved by stimulating vasculogenesis and neurogenesis and increasing the degree of vascularization of the tissue of the affected area of the GM by course administration of a protein-polypeptide complex with a tissue-specific reparative effect on nervous tissue in the form of Cellex®.

Disclosure of the essence of the invention

It is known that in order to ensure trophism, tissues must be vascularized. The delivery of the necessary material is carried out by the main blood vessels, and the exchange between blood and tissues occurs at the level of the capillary bed. Vascularization is the formation and proliferation of blood vessels, in particular capillaries, which leads to an improvement in tissue metabolism. To date, it has been shown that increased vascularization of healthy tissue in an organ leads to an increase in the organ. Under conditions of severe damage to GM and pronounced structural and functional changes that have arisen after traumatic, non-traumatic, or anoxic damage, this property becomes extremely important, since an increase in the metabolism of intact neurons leads to an increase in their functioning and stimulation of neurogenesis.

The authors of the proposed method have empirically found that the course of neurotrophic therapy of patients in the VS using the drug Cellex promotes the stimulation of angiogenesis and vascularization of GM tissue.

The protein-polypeptide complex, which is the basis of the Cellex® preparation, includes negatively charged weakly acidic, neutral proteins and polypeptides related to growth factors, differentiation, signaling molecules, molecules of intercellular adhesion, with molecular weights from 5 to 200 kDa, with at least 80% of the total mass of the protein has a molecular weight from 10 to 120 kDa, and is characterized by the presence of a peak at a wavelength of 274-284 nm in the UV region of the spectrum and the presence of bands in the range of pI values from 4.2 to 8.4 with isoelectric focusing in 5% polyacrylamide gel.

The main mechanisms of action of native embryonic protein and polypeptide molecules of Cellex® are as follows:

- primary neuroprotective effect of regulation / reduction of extrasynaptic concentrations of excitatory and thromotic neurotransmitter amino acids of the cascade of pathogenetic reactions of tissue hypoxia / GM ischemia due to the activation of glial and neuronal transporters of aspartate and glutamate (EAAT1-5, GLT-1) and an increase in the concentration of inhibitory neurotransmitters (GABA and TAU) by activating the aminobutyrate shunt;

- the secondary neuroprotective effect is due to inhibition of apoptosis processes due to the activation of autophagy by the action of native proteins of the drug group Bcl-2, DRP-1, TSC1, AMPK, CAIP1-2, c-FLIP, activation of receptors by growth factors and neurotrophins (inhibition of apoptosis), groups C-Myc, mTOR, Atg 1, Beclin-1, PTEN, LAMP-2, 1PI-3K / PKB, etc. (activation of autophagy).

Vascularizing properties have not previously been shown in patients with gross lesions of the GM and have not been described for Cellex. All drugs of a similar protein nature in this category of patients were used empirically and did not show the described properties. The convenient form of administration (subcutaneous route of administration), a small amount of the drug (2 ml), a prolonged period of the perfusion effect (28 days), clinical improvement in the condition of severe GM damage, allow us to speak with confidence about the advantages of using the drug in this category of patients who have undergone traumatic , non-traumatic or anoxic damage to GM at a dose of 0.2 mg-2 ml / day, subcutaneously, in the area of the skin fold of the deltoid muscle, for 15 days, daily.

A significant advantage over other drugs in this group is the subcutaneous route of administration of the Cellex® drug, which is especially important in patients who have been in the VS for a long time and who are at risk of developing complications after intramuscular administration. This method of administration is the most optimal, along with the high efficiency of the drug. The compliance of the subcutaneous administration of Cellex® does not raise doubts against the recommended intravenous infusions (difficulty of bolus administration) or intramuscular injections (acidosis of muscle tissue complicates the absorption of the drug and increases the degree of peptide biodegradation).

The optimally effective daily dose of Cellex® is 0.1 mg (in terms of total protein), with a single subcutaneous injection, is sufficient to stimulate the cellular receptors of nerve cells with differentiation and growth factors, neurotrophins and intercellular adhesion molecules, transforming growth factors and regulators of apoptosis / autophagy, because their sufficient doses for molecular signaling are up to several tens of nanograms, which is tens to hundreds of times lower than the minimum effective doses of conventional drugs-analogues, comparable to the doses of peptide-amino acid parenteral nutrition. This difference allows you to minimize adverse reactions when using the drug Cellex®, explains the almost absence of undesirable phenomena associated with its intake. Implementation of the invention

Taking into account the indications and contraindications, according to the instructions for the use of the drug, after the diagnosis of the state of consciousness (according to the Glasgow, FOUR, CRS-R scales) and the neurological status of the patient, the pharmaceutical composition of the Cellex protein-polypeptide complex is administered subcutaneously at a dose of 0.2 mg / day. subcutaneously, in the area of the skin fold of the deltoid muscle, for 15 days, daily.

Clinical research.

The study included 15 patients in prolonged unconsciousness (persistent VS or the state of minimal consciousness (CMC)) after suffering severe GM injuries at the age of 28 to 35 years, the average age was 28.5 ± 6.7 years. The cause of unconsciousness in 6 (40%) patients was hypoxic damage to GM, in 5 (35%) patients - severe traumatic brain injury (TBI) and in 4 (25%) patients - acute cerebrovascular accident (ACVI). VS was diagnosed in accordance with international criteria adopted at the International Congress of Rehabilitation Medicine in 1995 and approved in 2001 at the European Congress of Intensive Care Medicine in Brussels. The state of minimum consciousness (CMC) - according to the criteria proposed in 2002 by an international group of experts (Aspen Workgroup). At the beginning of the study, VS was found in 12 (80%) patients and CMC "-" in 3 (20%) patients. The study did not include patients with oncological pathology, patients who underwent surgical interventions for GM with the presence of a post-trepanation defect, with an episode and severe somatic complications.

In neurological status, patients with TBI were observed oculomotor disorders (in 3 patients in the form of divergent strabismus and in 1 patient - Hertwig-Magendie syndrome), asymmetric dissociated movement disorders in the form of tetrasyndrome of varying severity (in 8 patients) with anisoreflexia, dissociated anisotonia of mixed (pyramidal-extrapyramidal) type with a predominant tendency to spasticity (in 9 patients) of varying severity. Among patients with post-hypoxic lesion, movement disorders in the form of symmetric teraparesis (in 2 patients) or plegia (in 2 patients) with mixed pyramidal-extrapyramidal changes in muscle tone and a predominance of the latter, spontaneous or induced hyperkinetic and / or choreoathetoid forms of extrapyramidal syndrome (in 1 patient).

In the group of patients with ACVA, neurological symptoms corresponded to focal lesions of GM and were represented by oculomotor disorders in the form of gaze paresis, facial asymmetry, deep hemisyndrome with anisoreflexia, anisotonia (in 2 patients) or deep hemisyndrome to plegia within tetraparesis (in 2 patients).

All patients underwent therapy with the Cellex protein-peptide complex by subcutaneous injection at a dose of 0.2 mg / day, subcutaneously, in the area of the skin fold of the deltoid muscle, for 15 days, daily, without interruption against the background of basic therapy.

Clinical assessment of the patient's condition was carried out on the 1st day (before the start of drug use), on the 5th and 15th days of drug administration and included an assessment of the level of consciousness using the Coma Recovery Scale - Revised (CRS-R) , coma scales FOUR; study of neurological status (dynamic study of reflexes of the trunk of the brain, functions of cranial nerves, tendon and periosteal reflexes, autonomic disorders) with an assessment of changes in muscle tone according to the Ashfort scale.

To objectify these changes in cerebral blood flow during the use of the drug, we used the technique of perfusion CT (PCT) GM on a CT 64 Siemens SOMATOM Perspective manufactured by Siemens (Germany) by intravenous administration of a non-ionized low-osmolarity triiodinated X-ray contrast agent Ultravist (Bayer Pharma AG, D-13342, Berlin, Germany). PCT was performed before starting therapy, as well as on the 5th and 10th days of drug administration.

To assess the structural damage to the GM, data from neuroimaging methods were used: magnetic resonance imaging (MRI) in the T1, T2, FLAIR modes. Statistical data processing was carried out using the Statistica 6.0 software package. In all cases, nonparametric tests were used. To assess the dependencies, the Spearman rank correlation coefficient was used, to compare two dependent observations - the Wilcoxon test, and two independent observations - the Mann-Whitney test. The results were considered statistically significant at p <0.05.

Research results

At the beginning of the study, the total value of the CRS-R scale was significantly lower (p <0.05) in patients with TBI in comparison with the values of the other two groups (Table 1), which corresponded to the severity of the condition. Persistent VS was diagnosed in all patients with TBI.

The dynamics of the examination of patients against the background of the therapy showed an improvement in the majority of the participants in the groups with head injury and stroke, both in terms of the level of consciousness and neurological status on the 5th and 15th days of treatment. There were no significant changes in the group of patients with PGE.

In accordance with the subparagraphs of the CRS-R scale in patients with TBI, by the 5th day of drug administration, we observed the appearance of "gaze fixation" in 1 patient, a decrease in spastic syndrome (by an average of 1 point on the Ashforth scale) in 1 patient and in 1 patient the emergence of "non-functional" communication; in the group of patients with stroke - “gaze fixation” and “pain localization” in 1 patient and “non-functional” communication in 1 patient. Changes in clinical and neurological status were reflected in a significant increase in the total values of the CRS-R scale by the 5th and 15th days of the study (p <0.05).

By the 15th day of drug administration, positive effects were observed among patients of all study groups. A significant increase in the total value of the CRS-R scale was recorded both in the groups with TBI and stroke, and in the group with PGE (p <0.05). On average, the increase in the total value of points in all groups was 1.5 points in the period from 5th to 15th days of the study.

In general, the change in the mean value of the total score of the CRS-R scale after 10 days in comparison with the initial period increased by 2.8 points in patients with TBI, 1.6 points in patients with PGE and 3.5 points in patients with stroke, which reached the degree of statistical significance (p <0.001).

In the clinical picture, we observed a further increase in the level of activity in patients with TBI in the period from 5th to 15th days of the study, the appearance of "non-functional" communication in another patient and in one - an increase to the level of consciousness corresponding to the exit from unconsciousness ( the emergence of "functional accurate" communication). In the group of patients with ACVA, by the 15th day of the study, the appearance of “functional accurate” communication was determined in 2 patients, along with an increase in the score for the criteria for assessing “visual”, “motor” functions and the assessment of “wakefulness”.

Clinical example 1.

Patient K., 40 years old. Diagnosis: closed head injury, multiple severe GM bruises. Traumatic subdural hemorrhage. Sun.

Medical history: he was injured, underwent treatment in the intensive care unit of a multidisciplinary hospital, on the 23rd day from the moment of injury he was transferred to the department of anesthesiology and resuscitation of the FNKTS PP. Upon admission: the eyes open spontaneously, the gaze does not fix, the task does not fulfill, the level of consciousness meets the international criteria for the diagnosis of VS. Tetrasyndrome, with a predominant lesion of the right limbs, pseudobulbar disorders.

MRI of the brain: signs of post-traumatic contusion foci in the subconvexital parts of the frontal and temporal lobes, diffuse focal contusion-ischemic areas in the basal nuclei, in the cerebral peduncles and in the pons.

EEG: the data are typical for dysfunction of stem structures, mainly diencephalic with a predominance of synchronizing mesencephalic structures. Epic activity was not revealed.

The patient underwent subcutaneous injection of the protein-peptide complex Cellex at a dose of 0.2 mg / day, subcutaneously, in the area of the skin fold of the deltoid muscle, for 15 days, daily, without interruption.

In order to assess the perfusion characteristics, PCT was performed before the start of the course, on the 5th and 15th days of the drug use.

Scanning was performed at the level of the deep structures of the brain and basal ganglia with the capture of the supratentorial areas supplied by the anterior, middle and posterior cerebral arteries.

Cerebral perfusion was assessed by maps with quantitative values of regional cerebral blood flow constructed for each of the parameters, as well as by their absolute and relative values in the corresponding areas of the GM. As a result, the following parameters were calculated: volumetric blood flow rate - CBF (cerebral blood flow - ml / 100 g / min), blood flow volume - CBV (cerebral blood volume - ml / 100 g), mean transit time of contrasted blood - MTT (mean transit time - sec.), TTP is the time until the maximum (peak) concentration of the contrast agent is reached (time to peak, sec.).

The patient underwent a comprehensive CT examination of the GM, which included native CT and PCT under conditions of bolus contrast enhancement. PCT was performed from the level of the basal ganglia to the semioval centers.

Based on the PCT results, the following picture was observed:

In the first study, there was a decrease in the speed and volume of cerebral blood flow in the cortical regions of the right frontal and occipital regions, the periventricular white matter of the temporal and occipital regions of the right hemisphere.

The average transit time of contrast in these areas was also reduced. Cerebral blood flow was preserved except for the temporal and occipital lobes of the right hemisphere (Table 2).

5 days after the administration of the drug, a positive trend was observed in the form of an increase in speed indicators and blood flow in the gray matter of the frontal temporal and occipital lobes of both hemispheres (Table 3).

There was a decrease in the time until the maximum (peak) concentration of the contrast agent (CTP) was reached (Table 3).

The third study 15 days later showed further positive dynamics in the form of an improvement in the volumetric blood flow rate, blood flow volume, acceleration of the time to peak and passage of the contrast medium (Table 4).

Thus, there were signs of an increase in the cerebral blood flow velocity in the basin of both MCA with a preserved level of cerebral blood volume. Positive results of GM blood flow indicators correlated with the patient's neurological status during the study period. The patient showed a recovery in the level of consciousness, with an improvement in neurological status. This effect was observed starting from the 5th day of using the drug and prolonged up to 28 days after a 15-day course of using the drug. With the control PCT on the 27th day, the perfusion blood flow indices decreased slightly and did not reach the level of the previous studies. Considering that there was no dynamics in the neurological status for the previously carried out therapy with the use of intravenous, tablet forms of other neuroprotective drugs, it was the Cellex therapy that contributed to the restoration of consciousness in this patient.

Clinical example 2.

Patient S., 46 years old with a diagnosis of anoxic damage to GM. Was admitted on the 38th day after suffering a lesion. In the neurological status: not available to contact, does not follow commands, does not follow the examination, does not fix the gaze. Eye slits D = S, pupils D = S. Symptom Marinescu-Radovic on both sides. The face is symmetrical. Deep reflexes D = S. In case of painful irritation, non-targeted movements are noted in the left hand, in the right hand movements are insignificant. Spontaneous flexion movements are noted in both lower extremities. Muscle tone is increased. Babinsky's reflex is positive from 2 sides. Meningeal signs were not identified. The level of consciousness corresponds to the international criteria for the diagnosis of VS.

EEG: pronounced diffuse changes in the bioelectrical activity of the brain with signs of dysfunction of mesodiencephalic structures in the form of dysrhythmia with irregularities, significant instability and decreased cortical rhythm in combination with the dominance of slow-wave activity.

The patient underwent subcutaneous injection of the protein-peptide complex Cellex at a dose of 0.2 mg / day, subcutaneously, in the area of the skin fold of the deltoid muscle, for 15 days, daily, without interruption.

In order to assess the perfusion characteristics, PCT was performed before the start of the procedure, on the 5th and 15th days of drug use. PCT was performed from the level of the basal ganglia to the semioval centers.

Native examination of the GM revealed CT signs of hypodense zones in both frontal lobes of the GM, probably post-hypoxic changes. Moderate expansion of the external cerebrospinal fluid spaces and the ventricular system.

According to the results of PCT, the following changes were observed:

In the first study, there was a decrease in the velocity of cerebral blood flow in the cortical regions of the right frontal, both occipital regions, at the level of the basal ganglia of both hemispheres, with a simultaneous decrease in the volume of blood flow at the level of the temporal and occipital lobes of the right hemisphere. The time to reach the maximum (peak) contrast agent concentration was overestimated (Table 5).

In comparison with the previous study, 5 days after the administration of the drug, signs of positive dynamics were observed in the form of a significant improvement in perfusion indicators - signs of an increase in the volumetric blood flow rate, blood flow volume, acceleration of the time to reach the peak and the passage of the contrast agent (Table 6).

The third study showed further positive dynamics in the form of improved indicators of volumetric blood flow rate, blood flow volume, acceleration of the time to reach the peak and transit of the contrast medium (Table 7).

In comparison with previous studies, there was a positive trend in the form of restoration of perfusion in the right hemisphere of the GM, an increase in the velocity of cerebral blood flow in the frontal, temporal, occipital and basal nuclei on the left.

Thus, there were signs of an increase in cerebral blood flow velocity in the basin of both MCA with a preserved level of cerebral blood volume. Positive results of GM blood flow indicators correlated with the patient's neurological status during the study period. The patient showed a recovery in the level of consciousness, with an improvement in neurological status, and partial regression of motor disorders.

An increase in perfusion blood flow during the use of the drug in patients with severe GM damage, simultaneously with clinical improvement in the patient's condition, proves the need for neurotrophic therapy for this pathology (traumatic, nontraumatic or anoxic damage), and also indicates a new property of the drug - stimulating angiogenesis and tissue vascularization GM.

Claims (1)

A method for increasing the level of consciousness of patients in a vegetative state, which consists in stimulating vasculogenesis and neurogenesis and increasing the degree of vascularization of the tissue of the affected area of the brain by course administration of Cellex® at a dose of 0.2 mg / day, subcutaneously into the skin fold of the deltoid muscle daily for 15 days.