RU2145713C1 - Method for predicting isolated severe craniocerebral trauma outcome - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making lumbar puncture in lateral position at the level of the third-fourth lumbar vertebrae when the trauma is evaluated as 3-10 scores in Glasgow scale at the first to third day from the moment the patient is admitted in hospital. Plasminogen contents is to be determined in cerebrospinal fluid by applying solid phase immunoenzyme assay ELISA. Mean plasminogen index (MPI) in cerebrospinal fluid is calculated for predicting severe craniocerebral trauma outcome from formula: MPI=(P1

Description

 The method relates to medicine, namely to neurosurgery, resuscitation.

 Severe craniocerebral trauma (BMI) remains the most important problem of practical medicine. Already in the first hours after the injury, a clear differential diagnosis and prediction of a possible outcome is required.

 It is known that cerebrospinal fluid (CSF) is the internal environment in which the vital activity of brain cells is carried out. In this regard, the biochemical changes that occur in the CSF during PMTCT undoubtedly affect the recovery of brain functions, and therefore the outcome of the injury.

A known method for predicting the outcome of PMCT, based on the calculation of the discriminant sum by the formulas:
Y1 = 0.25X1 + 0.05X2 + 0.39X3 + 3.42X4 + 3.48X5 - 0.02X6 - 13.37
Y2 = 0.28X1 + 0.03X2 - 0.45X3 + 4.03X4 - 0.26X5 + 0.04X6 - 17.85,
where X1 is the age of the victim, X2 is the delivery time from the moment of injury, X3 is the open TBI coded 1, closed is 0, X4 is the degree of impaired admission, X5 is the number of eosinophils in the blood test (in%), X6 is the number of stab neutrophils in a blood test (in%). If Y2> Y1, the victim should be assigned to a group with a high risk of death. The accuracy of this prognostic model is 75% (IV All-Union Congress of Neurosurgeons, October 11-14, 1988, Leningrad; Abstracts, p. 39, Moscow ed., 1988).

 However, these formulas contain a number of signs, including such an indicator as the patient delivery time from the moment of injury, which is far from always possible to establish; the degree of impaired consciousness at the time of admission, which is a somewhat subjective sign. The above disadvantages do not always make it possible to use the recommended forecasting method. In addition, even with the correct collection of all data, the accuracy of this model is 75%.

 Known prognostic significance of short evoked potentials (self-sensory) during the first 4 days after PMI. A clear relationship was found between the presence of bilateral cortical potentials and a good outcome after PMI. In contrast, the lack of bi- or monolateral cortical potentials indicated an outcome with severe disability, prolonged vegetative state, or death of the patient (Critical Care Medicin. Official Journal of the sosiety of critical care medicine, vol. 18, april 1990, number 4, p. 363 -368).

 However, these data make it possible to predict not so much mortality among the studied category of patients, but to a greater extent reflect the degree of neurological deficit in the long-term post-traumatic period.

The closest, taken as a prototype, is a method for diagnosing the severity of a brain injury, including fractionation of CSF proteins by electrophoresis in a polyacrylamide gel followed by staining of electrophoregram proteins and densitometry, characterized in that the content of prealbumin, alpha-2 is determined to increase the accuracy of the method -macroglobulin, calculate the ratio K of the quantitative content of prealbumin to the quantitative content of alpha-2-macroglobulin according to the formula:
K = HpreA, where H preA and H a2Mg are the height of the peaks of prealbumin H a2Mg
and alpha-2-macroglobulin in the densitogram, and at K ≤ 0.5, a severe brain injury is diagnosed, at 0.5 <K ≤ 1.5, a moderate brain injury is diagnosed, with 1.5 <K ≤ 3, a lung brain injury is diagnosed degrees (RF patent N 2052206 "Method for diagnosing the severity of a brain contusion", M. CL G 01 N 33/68, prior. 08.05.91, publ. 10.01.96, BI N 1).

 The disadvantage of this method is that only the severity of damage to the substance of the brain is estimated, and the outcome of PMTCT is not predicted. In addition, the analysis of two proteins, and not one, as in the present method.

 The objective of the present invention is to improve the accuracy and objectification of the prognosis for the lives of patients with TBI in the first three days from the moment of injury.

The task is achieved in that in the CSF taken from the 1st and 3rd day from the moment of injury, the content of plasminogen is determined by enzyme-linked immunosorbent assay; the average plasminogen is calculated by the formula:
SPP = (P1 + P2) / 2 mg / l,
where P1 is the plasminogen content in the CSF on the 1st day,
P2 - the plasminogen content in the CSF on the 3rd day, and with a value of SPP ≤ 1.65 ± 0.14 mg / l, a favorable outcome of the disease is predicted, and with a value of SPP> 1.65 + 0.14 mg / l, an unfavorable outcome is predicted diseases.

The essence of the method is as follows: for patients with BMI with a Glasgow score of 3-10 points on the 1st and 3rd day after the injury, a lumbar puncture is performed in the patient’s position on the side at the level of 3-4 lumbar vertebrae. The second milliliter of CSF is taken for research. In the CSF, the content of plasminogen is determined by the method of enzyme-linked immunosorbent assay ELISA. To predict the outcome of PMTCT, the average CSF plasminogen (SPP) is calculated by the formula:
SPP = (P1 + P2) / 2 mg / l,
where P1 is the plasminogen content in the CSF on the 1st day,
P2 - plasminogen content in the CSF on the 3rd day.

 The patient's SPP is compared to normal. The CSF plasminogen indicator was accepted as the norm = 1.65 ± 0.14 mg / l, determined by numerous studies in practically healthy people (patients examined for osteochondrosis). The results were processed by conventional methods of variation statistics, analyzed in accordance with the outcome of PMCT. The data are presented in table 1.

 As can be seen from the data in the table, with SPP ≤ 1.65 ± 0.14 mg / l, we can talk about a favorable prognosis for the patient's life. If SPP> 1.65 + 0.14 mg / l, then in this case the prognosis for the patient’s life is considered to be unfavorable.

 The proposed method allows already from the third day to predict the probability of survival of patients with PMTCT. The accuracy of this predictive model according to our results is 96%.

The novelty of the method:
The method extends the possibility of additional diagnosis of severity of PMTCT.

 - From the third day it is possible to predict the outcome of PMTCT.

 - The inventive forecast method is based on the determination of one objective indicator - CSF plasminogen.

 The method can be applied in practical neurosurgery, neuroresuscitation in conjunction with traditional methods for diagnosing the severity of PMTCT.

 Comparison of the claimed method with the existing ones allowed us to establish compliance with the criterion of "novelty."

 Signs and results that distinguish the proposed subject from known in the study of publications in this field of medicine were not identified, therefore, meet the criterion of "significant differences".

 Example 1. Patient N., 42 years old.

 He was admitted to the hospital with a diagnosis of Closed severe traumatic brain injury. A brain contusion with compression of an acute subdural hematoma in the left frontotoparietal-temporal region in the stage of gross clinical decompensation. Edema and dislocation of the brain. Coma II, Glasgow score of 6 points. The operation was performed: cranioplastic trepanation of the skull, removal of acute subdural hematoma in the left frontoparietal-temporal region. After the operation, in an extremely serious condition, he entered the neuroresuscitation department, where ventilation was started in the hyperventilation mode. Complex therapy was prescribed: antibacterial, desensitizing, glucocorticoids, vasoactive drugs, transfusions of plasma and blood substitutes, water-electrolyte balance correction, vitamin therapy were carried out.

 On the first day, the CSF plasminogen indicator was 0.419 mg / L. On the third day, this figure was 0.334 mg / L. The formula calculated the SPP equal to 0.38 mg / L. When comparing with the norm (1.65 ± 0.14 mg / l), it is obvious that the patient’s SPP is significantly lower than the control, which made it possible to predict a favorable outcome for the patient’s life. Indeed, from the third day the patient regained consciousness to stupor (Glasgow 10 points), on the fifth day the patient was extubated, on the seventh day he was transferred to the general department, from where he was subsequently discharged in satisfactory condition. It should be noted that for the treatment of the patient the above standard therapy was sufficient.

 Example 2. Patient L., 18 years old.

 He was admitted to the hospital with a diagnosis of Open severe traumatic brain injury. Gunshot penetrating wound of the skull in the occipital region with the formation of acute subdural hematoma and crushing of the brain substance. Coma I art., Glasgow com score 7 points. The operation was performed: resection craniotomy, removal of acute subdural hematoma, revision of the wound canal. After the operation, in an extremely serious condition, he entered the neuroresuscitation department, where ventilation was started in the hyperventilation mode. Complex therapy was prescribed: antibacterial, desensitizing, glucocorticoids, vasoactive drugs, transfusions of plasma and blood substitutes, water-electrolyte balance correction, vitamin therapy were carried out.

 On the first day, the CSF plasminogen indicator was 3.520 mg / L. On the third day, this figure was 2.260 mg / l. The formula calculated the SPP equal to 2.89 mg / L. When compared with the norm (1.65 ± 0.14 mg / l), it is obvious that the patient’s SPP is significantly higher than the control, which allowed to predict an unfavorable outcome for the patient’s life.

 In this regard, along with standard complex therapy, the patient underwent such treatment methods as liquorosorption and intracarotid infusion of drugs (in particular, proteinase inhibitors). These methods are undoubtedly more invasive and are accompanied by a greater risk of complications, but with such a forecast they are justified. However, despite the treatment, the patient’s condition worsened over time and a fatal outcome occurred on day 12.

Claims (1)

A method for predicting the outcome of an isolated severe traumatic brain injury, including the study of cerebrospinal fluid protein, characterized in that in the cerebrospinal fluid taken on the 1st and 3rd day from the moment of injury, the plasminogen content is determined by enzyme-linked immunosorbent assay, the average indicator is calculated plasminogen according to the formula
SPP = (P1 + P2) / 2 mg / l,
where P1 - the content of plasminogen in the cerebrospinal fluid in the 1st day;
P2 - the content of plasminogen in the cerebrospinal fluid on the 3rd day,
and with a value of SPP less than or equal to 1.65 ± 0.14 mg / l, a favorable outcome of the disease is predicted, and with a value of SPP greater than 1.65 ± 0.14 mg / l, an unfavorable outcome of the disease is predicted.

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