RU2178179C1 - Method for predicting the brain trauma disease development course - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves taking venous blood sample at the second day after trauma. Lipid peroxidation index, malonic dialdehyde concentration, total peroxidation activity, Schiff base contents are determined. 20 g epithalamine diluted with 10 ml of isotonic sodium chloride solution is intravenously administered after taking blood. Venous blood is repeatedly taken from the patient 6-8 h later after administering epithalamine for determining the same values like lipid peroxidation index, malonic dialdehyde concentration, total peroxidation activity, Schiff base contents. Lipid peroxidation index values before and after administering epithalamine are compared. The lipid peroxidation properties being reduced - malonic dialdehyde concentration and total peroxidation activity less than by 30% each and Schiff base contents less than by 15% - unfavorable brain trauma disease development course is to be predicted. EFFECT: reduced probability of traumatic complications; simplified examination method.

Description

 The invention relates to medicine, namely to neuroresuscitation, neurosurgery (neurotraumatology), and can be used to predict the course of traumatic brain disease (TBHM) in patients with traumatic brain injury.

 The number of victims of traumatic brain damage is increasing every year. Traumatic brain injury (TBI), both isolated and combined, is accompanied by brain damage, which is the “trigger” in the development of TBHM, an unfavorable course of which often leads to patient disability or death (Neurotraumatology: Handbook, ed. A. N. Konovalova. - M.: CPC "Vazar-Ferro", 1994, p. 181; Starchenko A. A., Khlunovsky A. N. The concept of a damaged brain disease in clinical neuroresuscitation // Resuscitation at the turn of the XXI century / Materials International Symposium - M., 1 996, p. 168-170). Therefore, the timely and reliable prognosis of the course of this pathology is so important, which allows us to develop the optimal tactics of intensive care and reduce the negative consequences of TBHM.

 Conducted research on the medical-scientific and patent literature revealed various methods for determining the severity, dynamics of the head injury and predicting the course of TBHM.

 So, in an article by Alimov R.A., Frolov V.I., Dosmukhamedova Kh.K. Assessment of the severity of patients with combined craniocerebral injury // Med. Journal of Uzbekistan, 1990, 3, p. 30-32, a method is described for assessing the condition of patients with a traumatic brain injury by changing the magnitude of the indicator of the intensity of the reaction of the body - the ratio of the number of neutrophilic leukocytes to lymphocytes (neutrophilic leukocyte index - NLI) in the victim's blood. However, despite its simplicity, this method requires a significant investment of time, since it involves daily dynamic monitoring of NLI, an objective assessment of treatment results and its correction.

 In the article Krylova V.E., Lazareva L.V., Zyangirova S.T. Predicting the dynamics of the course of traumatic brain injury // Kazan Medical Journal, 1992, v. 73, 2, p. 93-96, a method for predicting the dynamics of the course and outcome of TBI by changing the activity of cholinesterase in arterial (in the common carotid artery) and venous (in the jugular vein) blood is described. This method is based on determining the deviation of cholinesterase activity in the arteriovenous difference in the blood flowing in and out of the brain and calculating the severity index of TBI in normal and pathological conditions. However, this method is quite traumatic and also requires considerable time to predict the course of head injury.

 In the work Korolyuk M.A., Ivanova L.I., Mayrova I.G., Tokareva V.E. Method for determination of catalase activity // Laboratory Case, 1988, 1, p. 16-19, it is proposed to use catalase activity in the cerebrospinal fluid of the victims as a prognostic indicator for brain injuries. However, this method for predicting the course of TBHM is also traumatic, quite complicated, which is associated with the collection of cerebrospinal fluid from the victim and its further investigation, and not always, especially with severe combined head injury, can be applied.

 In USSR author's certificate 1422154, published in B.I. 33, 1988, describes the "Method for determining the severity of brain damage in traumatic brain injury" by determining on a scale of arbitrary units in a peripheral blood sample taken after 18-24 hours after isolated TBI, the level of activity of alkaline phosphatase neutrophils. According to the values of this indicator, concussion or a bruise of the brain of a mild degree, or a bruise of the brain of moderate severity, or a bruise of the brain of a severe degree are determined.

RF patent 2052206, published in B.I. 1, 1996, protects "A method for diagnosing the severity of a brain injury" by determining the ratio of the quantitative content of prealbumin to the quantitative content of α ₂ -macroglobulin in the patient's cerebrospinal fluid. A brain injury of a severe, moderate or mild degree is diagnosed depending on the value of this relationship.

 In the application of the Russian Federation for the invention 98102049/14, published in B. I. 8, 1999, describes a "Method for the diagnosis of traumatic brain injury", including morphological examination of a patient's cerebrospinal fluid, centrifugation, filtering of cerebrospinal fluid, adding a crystal-forming substance to it, thermostating, further comparison of the obtained cerebrospinal fluid with the cerebrospinal fluid of a healthy person and the determination in it of the presence or absence of growth of crystal colonies, changes in their shape, structure, their area and density of crystallization centers. Assessment of the pathological process is carried out by the presence or absence of these signs.

 The RF application for invention 97107508/14, published in B.I. 11, 1999, describes a "Method for predicting the outcome of an isolated severe traumatic brain injury", including the study of cerebrospinal fluid protein (CSF), the determination of plasminogen content in CSF taken on the 1st and 3rd day from the moment of injury, the calculation of the average rate of plasminogen (SPP). Depending on the value of the SPP, a favorable or unfavorable outcome is predicted.

 RF patent 2140645, published in B.I. 30, 1999, protects "A method for assessing the severity of patients with traumatic brain injury in the acute period" by examining the patient’s blood and determining the effective concentration of albumin in blood serum. Depending on its value, the development of the negative dynamics of the disease is evaluated.

 The disadvantage of the above methods is that they are either traumatic, or insufficiently reliable, or complex and require significant time costs.

 The closest in technical essence and selected as a prototype is protected by RF patent 2146060 (IPC G 01 N 33/92, 33/48, published in B.I. 6, 2000) "Method for determining the severity of traumatic brain injury" providing for the study of the cerebrospinal fluid of the victim and the determination in it of the concentration of lipid peroxidation products - malondialdehyde (MDA) and diene conjugates (DC). Depending on the degree of increase in the concentration of MDA and DC, either a mild brain injury, or a moderate brain injury, or a severe head injury are diagnosed.

 However, this method is traumatic and quite complicated and time-consuming, which is associated with repeated collection of cerebrospinal fluid from the victim and its further investigation to predict the course of TBHM, and not always, especially with severe combined head injury, can be applied.

 The aim of the present invention is to reduce the morbidity and simplification of the method for predicting the course of TBHM with severe head injury, both combined and isolated.

 This goal is achieved by the fact that on the second day after the injury, the victim takes venous blood, which determines the values of lipid peroxidation (LPO): the concentration of malondialdehyde - MDA, total peroxidase activity - SPA, the content of Schiff bases - SHO. After blood sampling, the patient is injected intravenously with 20 mg of epithalamin diluted in 10 ml of isotonic NaCl solution. 6-8 hours after the administration of epithalamine, venous blood is re-collected from the patient, in which the values of the same parameters of LPO — MDA, SPA and SHO — are again determined.

 The values of the corresponding LPO indicators obtained before and after the administration of epithalamin are compared with each other, and with a decrease in the LPO values: MDA and SPA - by less than 30% each, SHO - less than 15% predict an unfavorable course of TBHM.

 The method is as follows.

 On the second day after the injury, 5 ml of venous blood is collected from the patient (from the central or peripheral vein), in which the values of the LP parameters are determined (MDA, SPA and SHO).

Determination of the concentration of malondialdehyde (MDA) in blood plasma is carried out according to the method, which is based on the formation of a colored trimethyl complex of MDA with two molecules of 0.68% thiobarbituric acid (Steel I. D, Gorishvili T. D. Method for the determination of malondialdehyde using thiobarbituric acids. - In the book: Modern methods in biochemistry. - M.: "Medicine", 1977, S. 66-68). Previously, blood samples are centrifuged at 3000 rpm for 15 minutes to obtain blood plasma. To 0.2 ml of plasma add 1 ml of 33% trichloroacetic acid and 1 ml of 0.75% thiobarbituric acid, mix and place in a boiling water bath for 15 minutes. The resulting sample is centrifuged at 3000 rpm for 15 minutes. The resulting supernatant is photometered on a KFK-2PM photoelectrocalorimeter at a wavelength of 535 nm. The concentration of MDA is recounted using a molar extinction coefficient equal to 1.56 • 10 ⁵ M ^-1 • cm ^-1 , and expressed in nmol per 1 ml of plasma (nmol / ml).

 The total peroxidase activity (SPA) in blood plasma is determined by a method based on the oxidation of benzidine with hydrogen peroxide to form intensely colored products with peroxidase activity (Lukash A.I., Vnukov V.V., Ananyan A.A., Milyutina N.P., Kvasha P.N. Metal-containing compounds of blood plasma during hyperbaric oxygenation. — Rostov-on-Don, 1996, p. 89). Previously, blood samples are centrifuged at 3000 rpm for 15 minutes to obtain blood plasma. To 4 ml of acetate buffer (pH 4.5) saturated with benzidyl sulfate with the addition of 3% hydrogen peroxide in a volume of 1 ml per 100 ml of saturated solution, add 0.02 ml of plasma, mix and photometer on a KFK-2PM photoelectric calorimeter at a wavelength of 600 nm . The result is expressed in units of maximum optical density per 1 ml of plasma (conventional units / ml), taking into account a correction factor of 0.02.

 The content of Schiff bases (SHO) is measured in the sample lipid extract according to the method of Bidlack, Tappel (1973) on a spectrofluorimeter manufactured in Japan (Hitachi 650-60) at a wavelength of 360 nm and expressed in relative units of fluorescence in 1 ml of plasma (rel. . / ml) (Bidlack WR, Tappel AS Fluorescent. Products of phospholipids during lipid peroxidation. // Lipids. - 1973. - 8.-P. 203). Previously, blood samples are centrifuged at 3000 rpm for 15 minutes to obtain blood plasma. To obtain a lipid extract (Bligh, Dyer, 1959), 0.5 ml of a plasma sample is treated with a mixture of methanol, chloroform and distilled water (8 ml: 8 ml: 4 ml) with constant stirring and left for 1 hour to extract the lipid fraction (Bligh E ., Dyer WJ Rapid method of total lipid extraction and purification // Can. J. Biochem. Physiol. -1959. V. 37. - 8. - P. 911 -917).

 After blood sampling, the patient is injected intravenously with 20 mg of epithalamin diluted in 10 ml of isotonic NaCl solution. 6-8 hours after the administration of epithalamin, the patient is re-sampled with 5 ml of venous blood, in which the values of the same LPO parameters (MDA, SPA and SHO) are determined again by the above methods.

где П_МДА1 - значение МДА до введения эпиталамина, П_МДА2 - значение МДА после введения эпиталамина,

где П_СПА1 - значение СПА до введения эпиталамина, П_СПА2 - значение СПА после введения эпиталамина,

где П_ШО1 - значение ШО до введения эпиталамина, П_ШО2 - значение ШО после введения эпиталамина.Then, according to formulas (1), (2) and (3), the change η _MDA values of MDA, the change η _SPA values of SPA and the change η _SHO values of SHO after the introduction of epithalamin are determined:

where P _MDA1 is the value of MDA before administration of epithalamine, P _MDA2 is the value of MDA after administration of epithalamine,

where P _SPA1 is the value of SPA before administration of epithalamine, P _SPA2 is the value of SPA after administration of epithalamine,

where P _SHO1 - SHO value before epithalamin administration, P _SHO2 - SHO value after epithalamin administration.

 With a decrease in the values of the FLOOR: MDA and SPA parameters by less than 30% each, SHO - by less than 15%, an adverse course of TBHM is predicted.

 Based on the results of the prognosis, the patient is corrected for an intensive care course.

 The theoretical prerequisite of the claimed invention was to assess the importance and the relationship between the severity of TBHM and changes in the values of LPO - MDA, SPA and SHO in the patient's venous blood in response to the introduction of epithalamine on the second day after the injury, leading to a decrease in the activation of LPO processes.

 The blood test of the victim is carried out precisely on the 2nd day after the injury, since by this time, as a rule, on the one hand, there is a relative stabilization of the patient's condition due to removing him from the shock and improving the rheological properties of the blood, and on the other hand, foci of ischemia are limited and the formation of foci of traumatic necrosis in the brain (Kasumova S. Yu. Pathomorphology of craniocerebral injury // Neurotraumatology. Handbook. - Rostov-on-Don, 1999, p. 187-191). This allows you to evaluate the functionality of brain tissue (not damaged irreversibly as a result of the injury) with minimal impact on the processes occurring in the body during the shock period.

 Activation of LPO processes is a vivid indicator of the degree of metabolic disturbance and the severity of destructive processes both in the body as a whole and in brain tissue, and the course of TBHM depends on the degree of structural changes in the brain tissue and on the severity of metabolic metabolic changes. LPO indicators are the most informative in the study of the development of this pathology (Sutkova D.A., Pedachenko E.G., Malyshev O.B. et al. Study of the activity of free radical peroxidation reactions in the acute and long-term period of severe head injury // Medical business, 1999 , 2, pp. 57-59), and the dynamics of changes in the values of the LP indicators (MDA, SPA and SHO), as shown by clinical studies, serves as an objective criterion for predicting the course of TBHM.

 Epithalamin (approved by the USSR Pharmacological Committee on June 19, 1990, reg. 90/250/6) allows mobilizing the functional activity of viable (not irreversibly damaged) brain cells involved in the processes of maintaining neuroendocrine balance in the body. Intravenous administration of the drug leads to a significant acceleration (already within 6-8 hours, depending on the severity of the head injury) of metabolic metabolic recovery processes by performing bioregulatory functions at the level of intercellular interactions (Morozov V.G., Khavinson V. Kh. Peptide bioregulators 25 years of experience in experimental and clinical studies. - SPb.:, 1996, p. 27; Havinson V. Kh., Morozov VG Preparations of the pineal gland and thymus in gerontology. - SPb.:, 1992, p. 6- 11) and, as clinical studies have shown, stabilization is significant th the above indicators of LPO. Thus, a repeated (6-8 hours after the administration of epithalamin) patient's blood test, determination of the values of the same LPO indicators (MDA, SPA and SHO) and the relative change in their values after the administration of epithalamin allows us to trace the dynamics of the metabolic metabolism recovery process and, thereby to predict the course of TBHM.

 In order to study the effectiveness of the proposed method for predicting the course of TBHM in the Department of Anesthesiology and Resuscitation of BSMP - 2, Rostov-on-Don, according to the claimed method, 56 people with severe combined head injury were examined. In 35 patients, a decrease in the values of each of the indicators of LP was observed: MDA and SPA - by less than 30% of each, SHO - by less than 15%, and an adverse course of TBHM was predicted. The further course of the disease confirmed a high degree of reliability in predicting the course of TBHM according to the proposed method.

 The practical application of the proposed method is illustrated by examples from clinical practice.

 Example 1

 Patient K., 20 years old, medical history 6673, was admitted to the Department of Anesthesiology and Resuscitation (ARO) for a severe closed head injury (severe brain contusion, subarachnoid hemorrhage) combined with a closed chest injury. Upon admission, the condition is extremely serious, the skin and visible mucous membranes are pale in color, HELL = 130/80 mm Hg. Art. , pulse = 98 beats. in min, BH = 22 in min, level of consciousness - coma I, pupils D = S, photoreaction is reduced, muscle tone is reduced. According to computed tomography (CT) of the brain: the median structures are not displaced, there is blood in the subarachnoid space. An ultrasound (US) examination of the abdominal organs revealed no pathology, free fluid was not determined. The patient was prescribed an intensive care complex, which included anti-shock, hemostatic, dehydration measures, as well as respiratory therapy (inhalation of moistened oxygen through a nasal catheter).

 On the second day after the injury, the patient from the peripheral vein was taken 5 ml of venous blood, which determined the values of the parameters of LPO: MDA = 12.80 nmol / ml, SPA = 6.97 conv. units / ml, SHO = 0.714 rel. units fl. / ml After blood sampling, the patient was intravenously injected with 20 mg of epithalamin diluted in 10 ml of isotonic NaCl solution. 7 hours after the administration of epithalamine, the patient was again taken 5 ml of venous blood, in which the values of the same LPO parameters were again determined. The following results were obtained: MDA = 10.25 nmol / ml, SPA = 5.33 conv. units / ml, SHO = 0.655 rel. units fl. / ml

Then, according to formulas (1), (2) and (3), respectively, the change η _MDA values of MDA, the change η _SPA values of SPA and the change η _SHO values of SHO after the introduction of epithalamin were determined. Calculations showed that there was a decrease in the values of each of the indicators of LP: MDA and SPA - by 19.9% and 23.5%, respectively, i.e., less than 30% of each, SHO - by 8.3%, i.e. e. less than 15%. The patient was given a prognosis of an adverse course of TBHM.

 The course of the disease proceeded in accordance with the unfavorable prognosis with the addition of purulent-inflammatory, neurotrophic and immune complications against the background of the development of diencephalic-catabolic syndrome. On day 28, the patient was transferred from the ARC to the department of combined and multiple trauma (OSMT), where he underwent treatment for 22 days.

 Example 2

 Patient M., 19 years old, medical history 9877, was admitted to the ARC department for a severe closed head injury (moderate brain contusion, subarachnoid hemorrhage), combined with a closed injury to the right knee joint. Upon admission, the condition is serious, the skin and visible mucous membranes are pale in color, HELL = 105/60 mm RT. Art. , pulse = 100 beats. per min, BH = 18 per min, level of consciousness - deep stunning, pupils D = S, normal photoreaction, muscle tone is reduced, shell symptoms are doubtful. According to CT: the middle structures are not displaced, there are traces of blood in the subarachnoid fissures. Ultrasound examination of the abdominal organs revealed no pathology; free fluid was not determined. The patient was prescribed an intensive care complex, which included antishock, hemostatic, dehydration measures.

 On the second day after the injury, the patient from the peripheral vein was taken 5 ml of venous blood, which determined the parameters of LP: MDA = 12.61 nmol / ml, SPA = 6.51 conv. units / ml, SHO = 0.643 rel. units fl. / ml After blood sampling, the patient was intravenously injected with 20 mg of epithalamin diluted in 10 ml of isotonic NaCl solution. 6.5 hours after the administration of epithalamine, 5 ml of venous blood was repeatedly taken from the patient, in which the values of the same FLOOR indices were again determined. The following values were obtained: MDA = 9.47 nmol / ml, SPA = 4.81 srvc. units / ml, SHO = 0.560 rel. units fl. / ml

Then, according to formulas (1), (2) and (3), respectively, the change η _MDA values of MDA, the change η _SPA values of SPA and the change η _SHO values of SHO after the introduction of epithalamin were determined. The calculations showed that there was a decrease in the values of each of the indicators of LP: MDA and SPA - by 24.9% and 26.1%, respectively, i.e., less than 30%, SHO - by 12.9%, i.e. less than 15%. The patient was given a prognosis of an adverse course of TBHM.

 The course of the disease proceeded in accordance with the unfavorable prognosis against the background of the development of purulent-inflammatory complications.

 Thus, in comparison with the prototype, the proposed technical solution allows to reduce the morbidity and simplify the prediction of the course of TBHM in severe TBI, both combined and isolated.

Claims (1)

 A method for predicting the course of traumatic brain disease (TBHM), which involves examining a biological fluid with a concentration of malondialdehyde - MDA in it, characterized in that venous blood is collected from the victim on the second day after the injury, in which, in addition to determining the MDA value, the values of other indicators of lipid peroxidation (POL): total peroxidase activity - SPA and content of Schiff bases - SHO, after blood sampling the patient is injected intravenously 20 mg of epithalamine diluted in 10 ml of an isotonic NaCl solution, 6-8 hours after the administration of epithalamine, venous blood is re-taken from the patient, in which MDA, SPA and SHO are determined again, and when the LPO: MDA and SPA values are decreased - less than 30% of each, SHO - less than 15% predict an adverse course of TBHM.