RU2209041C2 - Method for treating cerebral vasospasm - Google Patents

Abstract

FIELD: medicine, neurosurgery. SUBSTANCE: the suggested method deals with treating patients with developed secondary cerebral vasospasm after subarachnoidal hemorrhage as a result of arterial aneurism rupture of cerebral vessels. One should carry out clipping of arterial aneurism simultaneously with applying extraintracranial microvascular anastomosis (EICMA) between the branch of ipsilateral surface temporal artery and cortical branch of middle cerebral artery. Therapy course should be conducted including maintenance of systolic arterial pressure being 25-30% higher against "working" one and normovolemic variant of hemodilution. Moreover, minimum volume of infusion should be performed in nocturnal hours, and ratio of enterally injected liquid and intravenous infusion should be maintained to be 1: 6 during the 1st d, and then - 1:2. EFFECT: higher efficiency of therapy. 1 cl, 1 ex

Description

 The invention relates to medicine, namely to neurosurgery, and can be used in the treatment of patients with developed secondary cerebral vasospasm after subarachnoid hemorrhage due to rupture of arterial aneurysm of the cerebral vessels, accompanied by focal ischemic disorders or without clinical manifestations, confirmed by transcranial doppler ultrasonography, computed tomography.

 A known method of treating cerebral vasospasm (VV Lebedev, VV Krylov, VN Shchelkovsky. Clinic, diagnosis and treatment of intracranial arterial aneurysms in the acute period of hemorrhage. M: Antidor, 1996) by surgical intervention in the "cold" period "- with a decrease in the severity of clinical manifestations.

 However, intensive conservative therapy of vasospasm during the waiting period is limited by the presence of an unclipped (or unverified) aneurysm. In these patients, the possibility of developing repeated ruptures of aneurysms and hemorrhages remains, which is highly likely to lead to death. In addition, autologous hemolyzed blood is a toxic vasoconstrictor factor (NF Kassel, HP Adams. DI Boarmi et al. Results of early surgery for ruptured intracranial aneurism // Timing of aneurism surgery // Ed. By LM Auer. Berlin-New York, 1985 ), and intraoperative debridement of subarachnoid spaces in itself contributes to a reduction in vasospasm (J. Suzuki, T. Yoshimoto. Early operation for the ruptured intracranial aneurysms - especially the cases operated within 48 hours after the last subarachnoid hemorrhage / No-Shirikei-Geka. 1976 Feb; 4 (2): 135-41).

 - A known method of treating cerebral vasospasm by conducting triple-h (3-H) therapy, including controlled hypertension, hypervolemia and hemodilution (JL Martinez-Chacon Crespo. Anesthesia for the Surgery of Intracranial Aneurisms. Part 2.// The Internet Journal of Anesthesiology . 1998. V. 2. 2), and the required level of blood pressure is 200-240 torr, CVP is 7-10 cm Hg, which corresponds to 70-100 mm Hg. (H. Batjer, D. Samson. Use of Extracranial-Intracranial Bypass in the Management of Symptomatic Vasospasm // Neurosurgery. 1986. V. 19. 2. P. 235-246; Awad IA, Carter LP, Spetzler RF, et al Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension. // Stroke. 1987. V. 18 P. 365-372; Solomon RA, Fink ME, Lennihan L. Early aneurysm surgery and prophylactic hypervolemic hypertension therapy for the treatment of aneurysmal subarachnoid hemorrhage. // Neurosurgery. 1988. V. 23 R. 699-704). A prerequisite for triple-h therapy is round-the-clock invasive measurement of intracranial pressure, monitoring of basic hemodynamic and laboratory parameters.

 However, the isolated application of this treatment regimen carries the danger of developing quite formidable complications, including cerebral edema, pulmonary edema, and cardiac arrhythmias. In addition, the method cannot be applied in cases where the patient may have undetected or non-clipped aneurysms (H. Batjer, D. Samson. Use of Extracranial-Intracranial Bypass in the Management of Symptomatic Vasospasm // Neurosurgery. 1986 V. 19. 2 P. 235-246), which significantly limits its clinical use.

 A known method of treating cerebral vasospasm by endovascular dilatation of a spasm segment of an artery (Yu.N. Zubkov, B. M. Nikiforov, V. A. Shustin. Initial experience of dilatation of spasmodic cerebral vessels in the acute period of rupture of arterial aneurysms // Issues of Neurosurgery. 1983. 5. P. 17-23), sometimes followed by ballooning of the aneurysm (Yu.N. Zubkov, VB Semenyutin. Endovascular dilatation of cerebral vessels in patients with rupture of arterial aneurysms // 4th All-Union Congress of Neurosurgeons (11-14 Oct. 1988, Leningrad) / Abstracts s -. Moscow, 1988. - S. 120-121). The operation is performed by puncture of the OSA or the femoral artery, the introduction of a double-lumen vascular catheter and a dilated catheter through it with a latex balloon of a special design. A metal conductor, X-ray contrast and drug substances are passed through the second lumen. Under X-ray control, a dilatation balloon-catheter is carried out to the stenotic area, by gradually introducing a contrast agent into the catheter, mechanical dilatation of the proximal, then distal section of the spasm segment is carried out with the preliminary introduction of heparin. A permissible increase in the level of pressure in the vessel during endovascular dilatation of spasmodic sections of the arteries is considered to be a landmark of 200 mm Hg. (B.A. Purin, V.A. Kasyanov. Biomechanics of large human blood vessels. Riga: 3inatne, 1980). The operation is completed with control angiography.

 The disadvantages of this method include its inefficiency in regional and generalized vasospasm, as well as the existing likelihood of developing hemorrhagic complications. In addition, X-ray endovascular dilatation is possible only by specialists who are familiar with the technique of endovascular neurosurgical interventions under X-ray conditions with the appropriate equipment.

 Closest to the claimed is a method of treating angiospasm described by H. Batjer, D. Samson, 1986 (H. Batjer, D. Samson. Use of Extracranial-Intracranial Bypass in the Management of Symptomatic Vasospasm // Neurosurgery. 1986 V. 19. 2 P. 235-246).

 In patients with progressive angiospasm after subarachnoid hemorrhage due to rupture of an arterial aneurysm who underwent aneurysm clipping operation (average period of 4.8 days after hemorrhage), additional EICMA (ipsi or bilateral) was performed in the postoperative period.

 The technique of the operation consists in expanding the previous access (anterior temporal craniectomy), isolating the sylvian fissure to a cortical branch of the middle cerebral artery that is suitable in diameter and its temporary isolation. A section of the short Vena saphena parva is hemmed onto a section of a previously isolated branch of the superficial temporal artery (1.5–2 mm in diameter); an anastamosis is created with an autovenous insert between the cortical arterial branch and the superficial temporal artery.

 In the near postoperative period, monitoring of the main parameters of homeostasis is carried out. Assessment of the intracranial situation is based on indirect data. Control angiography is performed no earlier than 3 days after the operation.

 The disadvantages of this method of treatment include the need for reoperation against the background of progressive angiospasm in patients after clipping aneurysm. The technique of craniotomy is somewhat complicated - in all patients with arterial aneurysms, it is necessary to preserve the branches of the superficial temporal artery. No tactics have been defined for a group of patients with progressive vasospasm and verified unclipped arterial aneurysms.

 The authors do not use the favorable hemodynamic conditions that arise after applying EIKMA for 3-H therapy with a lower risk of complications and a greater clinical effect.

 The objective is to create an effective mechanism for the prevention and correction of ischemic disorders of cerebral circulation, which allows for surgical treatment in conditions of cerebral angiospasm, to reduce mortality and improve the functional outcomes of treatment of patients after subarachnoid hemorrhage due to rupture of arterial aneurysms of the brain vessels.

 When solving the problem, a therapeutic effect is achieved, consisting in reducing mortality and disability of this category of patients. This is due both to a decrease in the risk of repeated hemorrhage (surgical shutdown of the aneurysm becomes possible with vasospasm); and with a reduction in the duration of angiospasm and an improvement in clinical outcomes.

 The expected economic effect is associated with a reduction in budget costs due to a reduction in the hospitalization period for a patient of this category (according to our forecasts, by an average of 7 bed days), improved treatment outcomes without the use of a number of expensive drugs, and reduced rehabilitation costs.

 The social effect may be due to a decrease in the proportion of disabled people of working age among the population (54.4% of patients are young people aged 31 to 50 years), as well as with certain positive demographic consequences (37.7% of patients are persons under 40 years of age, male to female ratio 2: 3).

 The solution to this problem is achieved by the fact that the clipping of the aneurysm and the application of EIKMA are performed simultaneously, while conducting a course of therapy, including maintaining systolic blood pressure 25-30% higher than the "working" and normovolemic variant of hemodelation. The minimum amount of infusion is carried out at night, and the ratio of enteric fluid and intravenous infusion is maintained at 1: 6 on the first day, and then 1: 2.

 The proposed method is as follows. Patients with verified subarachnoid hemorrhage against the background of progression of the threatening phenomena of angiospasm (in the presence of clinical neurological data and doplerographic evidence - an increase in the linear blood flow velocity in the spasm vessel by 30-40 cm / s daily) undergo serial cerebral angiography. After confirming the diagnosis, clarifying the localization of arterial aneurysm (or multiple aneurysms), the prevalence and severity of angiospasm in the earliest possible time under general anesthesia, a two-stage operation is performed. At the first stage, after standard craniotomy (usually frontotemporal, with preservation of the superficial temporal temporal artery), microsurgical clipping of the revealed arterial aneurysms and thorough intraoperative sanitation of subarachnoid spaces from hemolyzed blood are performed.

 At the next stage, a branch of the superficial temporal artery is distinguished (diameter about 2 mm), it is separated from the aponeurosis for 4-5 cm and a microclip is applied at its distal end (with a small diameter of the branches, an anastamosis was created between the trunk of the superficial temporal artery and the largest diameter M2 with an autovenous insert from the site of Vena saphena parva). The vessel is closed with a padded coat moistened with a solution of papaverine hydrochloride. A microclip is applied to the proximal end of the branch of the temporal artery, the peripheral end of the vessel is washed with heparinized isotonic solution.

 In the basin of the most spasmodic vessel, a segment of the cortical artery convenient for anastamosis is determined (the most proximal branch of the middle cerebral artery at the exit of the sylvian fissure was most often used).

 The arachnoid membrane along the selected arterial segment is dissected for 1.5 cm, a rubber tread is placed under the artery, the perforating branches extending from the segment are coagulated and crossed, and 2 removable microclips are placed at the artery at a distance of 1.5 cm from each other. Then, the wall of the cortical branch is longitudinally dissected for 3-4 mm, the vessel is washed with an isotonic solution and, using filaments and needles 10/0, a microanastamosis of the end-in type is applied under the 25-fold increase between the selected cortical branch and the distal portion of the surface temporal artery branch. side by applying 5-6 microseams followed by sealing the area of the anastamosis with hemostatic Surgicell mesh. After applying the sutures, the distal, then the proximal clips from the cortical branch are removed, the tightness of the sutures is checked, and the clips are removed last from the superficial temporal artery. After checking the functioning of the anastamosis, in the absence of compression by surrounding tissues, suturing is performed.

 Using the described surgical technique for creating EIKMA allows you to slightly change the scheme of drug treatment of this category of patients, reduce its aggressiveness, thereby reducing the likelihood of developing complications.

 The first component of the triad - controlled hypertension - is realized by continuous infusion of dopamine at a dose of 5-8-10 μg / kg / min to maintain systolic blood pressure 25-30% higher than the "working" blood pressure of the patient.

 The second and third components - hypervolemia and moderate hemodilution - are achieved by fluid infusion. The total infusion volume is calculated as follows: Daily infusion volume = physiological need + fluid deficiency + compensation for pathological losses.

 Physiological need = 1800 ml per square meter of body surface area.

где Ht - гематокрит,
Д - дефицит жидкости.Liquid deficiency according to Rachev's formula

where Ht is the hematocrit,
D - fluid deficiency.

 The volume of fluid required to compensate for pathological losses (fever, paresis of the gastrointestinal tract, prolonged mechanical ventilation) is calculated by known methods.

 Mandatory is to record the time of day - the minimum amount of infusion at night.

 The traditional colloid: crystalloid ratio = 1: 3 is observed.

 As colloidal solutions, it is preferable to use solutions of hydroxymethyl starch in dosages recommended by the manufacturer, as well as a solution of 10% albumin in a dose of 5 ml / kg.

 Freshly frozen plasma is used to correct the coagulation potential of blood at a dose of 5-10 ml / kg under the control of a coagulogram.

 Immediately, when the motility of the gastrointestinal tract organs is restored, enteral administration of fluid begins, which reduces the load on the right heart and reduces the risk of hypertension in the pulmonary circulation and pulmonary edema. The ratio of enteral fluid and intravenous infusion on the 1st day is 1: 6, then 1: 2.

 The criterion for the adequacy of the water load is the presence of a hematocrit in the patient = 32-35%; central venous pressure = 0-5 mm water column

 A prerequisite for the use of 3-H therapy is the availability of round-the-clock monitoring of the electrocardiogram, invasively measured intracranial pressure, indicators of systemic hemodynamics (non-invasive blood pressure monitoring with automatic calculation of average blood pressure, central venous pressure, heart rate); as well as diuresis and laboratory parameters (coagulation, hematocrit, electrolytes and osmolarity of blood and urine). Optimal is monitoring the level of lactate - pyruvate in the blood flowing from the brain (in v. Jugularis).

 Assessment of cardiac output dynamics in patients with severe concomitant cardiac pathology is carried out by pressure in the pulmonary capillaries, in other patients - by an indirect method (dopplerography).

CLINICAL EXAMPLE
Patient K.P. S.P., 41, was delivered to the neurological hospital ICD 1 by the SMP machine on 10/16/99 after the first generalized epipressures with clonic-tonic seizures in the right extremities torpedic to drug influences.

 On admission, the condition is serious, convulsions continuing at intervals of 1 minute, accompanied by tachypnea and involuntary urination. The patient is asthenic (a history of pulmonary tuberculosis). HELL = 160/100 torr.

 Neurologically - SCH 8 points, pupils are wide, anisocoria (S> D), sluggish photoreactions. It was not possible to reliably evaluate strength and tone. Rigidity - 3 p. On the fundus - beginning stagnation of the optic nerve discs.

 Transferred to the intensive care unit of the neurological department. A CT scan of the brain was performed, signs of subarachnoid hemorrhage were detected in the projection of the right sylvian fissure. With TCD, angiospasm in the MCA pools is determined (on the right - coarser, ls = 165 cm / s, asymmetry of blood flow 16%, the decrease in hemodynamic reserves is determined).

 Despite the ongoing infusion, hypotensive, anticonvulsant therapy, the patient's condition remained severe: inadequacy, disorientation, lethargy, hypertension (AD = 160/100), meningeal symptoms persisted. There was paresis 7 p on the left, left-side hemiparesis (in the arm up to 3 b, in the leg - 2 b). With TCD, an increase in angiospasm was noted (linear velocity in the MCA increased on the right to 202 cm / s, on the left to 143 cm / s, depletion of collateral reserves was noted).

 10/25/99 transferred to the department. microneurosurgery, 3-H-therapy course started. 10.26.99 selective carotid angiography was performed, arterial aneurysm of the SMA on the right was verified, the phenomena of pronounced angiospasm, more pronounced in the pool of the right SMA. According to vital indications, 10.26.99 an operation is performed - microsurgical clipping of the neck of the SMA aneurysm on the right from the right pterygonal access, superposition of the EIKMA between the superficial temporal artery and the SMA branch on the right.

 He was transferred to the intensive care unit, where a postoperative course of 3-H-therapy was carried out. The first component of the triad - controlled hypertension - was implemented by continuous infusion of dopamine at a dose of 8-10 μg / kg • min to maintain systolic blood pressure 25-30% higher than the "working" blood pressure (130-80 torr) of the patient.

 The second and third components - hypervolemia and moderate hemodilution - were achieved by fluid infusion. The total infusion volume was calculated as follows: Daily infusion volume = physiological need + fluid deficiency + compensation for pathological losses.

 Physiological need = 1800 ml per square meter of body surface area, which amounted to 3.3 l / day.

где Ht - гематокрит,
Д - дефицит жидкости, 15,2=m (76 кг) :5;
Ht - гематокриг желаемый, равный 35.Liquid deficiency according to the Rachev form

where Ht is the hematocrit,
D - fluid deficiency, 15.2 = m (76 kg): 5;
Ht is the desired hematocrig equal to 35.

 The volume of fluid required to compensate for pathological losses (fever, prolonged mechanical ventilation) was calculated by known methods.

 Time-of-day accounting was mandatory - the minimum amount of infusion was at night.

 The traditional colloid: crystalloid ratio of 1: 3 was observed.

 As colloidal solutions, hydroxymethyl starch solutions were used - 2500 ml / day (at a dose of 33 ml / kg weight), as well as 380 ml of 10% albumin solution (5 ml / kg).

 Freshly frozen plasma was used to correct the coagulation potential of blood at a dose of 5 ml / kg under the control of a coagulogram.

 Immediately after restoration of gastrointestinal tract motility, enteral fluid administration began, which gradually reduced the load on the right heart and reduced the risk of hypertension in the pulmonary circulation and pulmonary edema. The ratio of enteral fluid and intravenous infusion on the 1st day was 1: 6, then 1: 2.

 A criterion for the adequacy of the water load was considered to be a hematocrit of 32-35%; central venous pressure 0-5 mm water

 A round-the-clock monitoring of the electrocardiogram, invasively measured intracranial pressure, and indicators of systemic hemodynamics (non-invasive blood pressure monitoring with automatic calculation of average blood pressure, central venous pressure, heart rate) was carried out; as well as diuresis and laboratory parameters (coagulograms, hematocrit, electrolytes and urine osmolarity). Assessment of cardiac output dynamics by indirect method (dopplerographic).

 In the morning hours 10/27/99 - the patient is conscious, adequate. With TCD, there is a sharp decrease in blood flow velocity in the right SMA (up to 64 cm / s) and a slight increase in its blood pressure in the left SMA (up to 187 cm / s), satisfactory functioning of the anastamosis. On the evening of October 27, 1999, a significant regression of focal and meningeal symptoms was noted - an increase in strength in the left extremities by 1-1.5 points, a decrease in rigidity to 1.5 p.

 11/01/99 transferred to the specialized department. In the future, against the background of nootropic therapy, a natural positive dynamics is noted - a complete regression of focal and meningeal symptoms. According to TCD, the asymmetry of blood flow is maintained with a predominance in the contralateral hemisphere (LSC up to 170 cm / s on the left, 60 cm / s on the right), the emergence of reserves of collaterals, good functioning of the anastamosis are noted.

 During control angiography (11.29.99), a complete shutdown of the arterial aneurysm of the SMA on the right, good contrast of the EIKMA, resolving angiospasm are determined.

 11.29.99 the patient was discharged under the supervision of a neurologist polyclinic.

Claims (2)

 A method of treating cerebral vasospasm, including clipping of an arterial aneurysm and the application of extra-intracranial microvascular anastomosis (EIKMA) between the ipsilateral superficial branch of the temporal artery and the cortical branch of the middle cerebral artery, characterized in that the clipping of the aneurysm and the application of EIKMA are performed simultaneously, while including maintaining systolic blood pressure 25-30% higher than the "working" and normovolemic variant of hemodelation.  2. The method according to claim 1, characterized in that the minimum amount of infusion is carried out at night, and the ratio of enteric fluid and intravenous infusion is maintained on the first day 1: 6, in the future - 1: 2.