RU2284749C1 - Method for carrying out patient rehabilitation and evaluating it in acute ischemic stroke period - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves applying drug therapy under ischemic lesion focus state control with magnetic resonance tomography (MRT) being used. Bioenergetic evaluation of focus state, its size and cerebral blood circulation condition are evaluated in dynamics. Therapy without drugs is concurrently applied for observing ischemic lesion focus at the end of acute period using MRT-mode with suppressed signal from free liquid surface. The MRT observation is started at the first two days from the ischemic stroke beginning.

EFFECT: enhanced effectiveness of treatment.

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Description

The invention relates to medicine and can be used to develop the most effective methods of treatment and activation of patients in the acute period of ischemic stroke (AI).

There is a method of intravital assessment in patients with a focus of acute ischemic damage and the dynamics of changes in it using magnetic resonance imaging (MRI). The methods used are diffusion - (DV-) and perfusion-weighted (PV-) MRI studies (Klimov L.V., Koshman A.N., Parfenov V.A., Ternovoi S.K., Yakhno N.N. Hemispheric prognosis ischemic infarction based on perfusion-weighted magnetic resonance imaging (Neurological Journal. 2004; 1, p. 32-35).

The technique of DV-MRI in post-stroke patients visualizes areas with a decreased proton diffusion rate, which indirectly indicates bioenergetic disturbances in these areas and makes it possible to identify areas that are most likely to undergo necrosis without reperfusion therapy.

The PV-MRI technique reveals areas of reduced cerebral blood flow (relatively healthy substance) by evaluating the passage of contrast medium along the microvasculature.

Closest to the invention is a method for the rehabilitation of patients and its assessment in the acute period of ischemic stroke by using drugs and monitoring the condition of the site of ischemic damage using MRI to assess the bioenergetic state of the site, its size and state of cerebral circulation before treatment and in dynamics (5 6 days of treatment and 3 months after a stroke) (PA Barber, MW Parsons, PM Desmond, et al. The use ofPWI and DWI measures in the design of "Proof-of-concept" stroke trials. J Neuroimaging 2004; 14: 123-132). The effectiveness of the applied drug therapy was evaluated in patients with the first 6 hours of AI: one group of examined patients received reperfusion therapy - tissue plasminogen activator (t-PA), the rest were prescribed neuroprotective therapy. Dynamic MRI research was performed in the first 6 hours from the start of AI; the second, in the subacute stage, between 3 and 5 days to assess the dynamics of MRI data, which, in addition to standard modes, included angiography of intracranial arteries, DV- and PV-MRI. The last study was carried out after 3 months to calculate the final size of the heart attack only in the standard mode with visualization of free fluid. In all patients, the neurological status and level of self-care were evaluated. However, according to this method, the opportunity to activate patients in the acute period of AI was not used due to the lack of data on the effect of various reconstructive methods on the site of ischemic damage.

Currently, more and more attention is paid to non-drug rehabilitation methods - motor recovery of patients, speech therapy, plasmapheresis, etc. Given that the maximum motor recovery occurs in the first days of AI, there is a need to use a method that determines the effectiveness of early rehabilitation methods and their combination.

It has already been proven that the use of non-drug rehabilitation methods, including early activation, significantly improves the outcome in post-stroke patients and increases the effectiveness of drugs.

There are the following methods for assessing the condition of the focus of acute ischemic damage: computed tomography (CT) examination, including CT perfusion; positron emission tomography. But the first does not allow to obtain complete information about the structural state of the substance of the brain, and the second is very laborious and requires large material costs, which prevents its use in wide clinical practice. Therefore, the method of choice today for the rehabilitation of patients in the acute period of ischemic stroke is to conduct an MRI scan in various modes, as a result of which it is possible to get an idea of both structural disorders and the blood supply to the brain.

Given the cost of the examination and often the difficult and unstable state of patients with acute AI, it is necessary to limit the number of MRI modes as much as possible. At the same time, it is necessary to obtain all the necessary characteristics of the lesion. In the prototype method, the effectiveness of only drug therapy is evaluated. Moreover, a large number of regimes were used (including expensive angiography), the use of which in everyday practice of studying “acute” patients is impossible due to the severity of their condition and often inadequacy. The remote conduct of the last study (the third one - 3 months after the IS) does not allow to evaluate treatment in terms of hospitalization, significantly complicating the planning of further tactics of patient management. Using the standard mode without suppressing the signal from the free fluid does not allow us to accurately assess the size of myocardial infarction in areas close to liquor-containing spaces that have a hyper-intense signal, as well as myocardial infarction. And the performance of PV-MRI, not across the entire lesion by DV-MRI, limits the ability to determine the size of hypoperfusion zones. In addition, in the prototype method, the study included patients of the first 6 hours of AI. Although it is known that the focus of acute ischemic damage can decrease in size with the right treatment within 48 hours from the time of the development of a stroke.

The technical result of the invention is to improve the quality of patient rehabilitation and its assessment in the acute period of ischemic stroke, namely motor recovery, training of higher cortical functions, various physiotherapeutic methods.

It is achieved by the fact that in the indicated method of rehabilitation and its assessment, which consists in the use of therapeutic measures in the form of drug therapy and monitoring the condition of the lesion site of ischemic damage using MRI to assess the bioenergetic state of the lesion, its size and state of cerebral circulation before treatment and at 6 days of treatment, therapeutic measures are carried out in patients with the first two days of ischemic stroke, and non-drug therapy is included in them, and assessment of the condition of the lesion begins in patients with the first two current from the beginning of the AI and on day 21, using the mode with suppression of the signal from the free liquid.

According to the proposed method, rehabilitation measures are carried out for patients in the first two days from the moment of AI development due to the possible reversibility of their changes in DV-MRI, i.e. the effectiveness of the treatment in these terms. This allows you to optimize treatment tactics in more patients. The first study is carried out before treatment with obtaining images in the regimes with suppression of free fluid, DV- and PV-MRI with visualization of the entire lesion. The second study is carried out during treatment for 5-6 days. The terms of the study are due to the need for the earliest possible preliminary assessment of the impact of rehabilitation measures on the focus of acute ischemic damage with the subsequent cessation of these measures in the event of adverse effects.

The third study is carried out on day 21, because during these periods, as a rule, the treatment carried out in the early rehabilitation period is completed. The study of DV-MRI is carried out in order to control the appearance of new foci of bioenergetic disorders against the background of active treatment.

PV-MRI is not used due to its high cost and the absence of changes in images at these times.

An example implementation of the method

25 patients (mean age 64 years) were examined in the first 48 hours of ischemic stroke (II) in the middle cerebral artery basin. From the time of admission, all patients received standard treatment, which included vasoactive and neuroprotective therapy. All patients were divided into two groups: the main (11 people) and control (14 people).

Patients of the main group were additionally given early rehabilitation treatment in the form of neuromuscular electrical stimulation of the paretic arm for 21 days. To assess the dynamics of recovery of patients, their neurological deficit was determined according to the NIHSS scale at admission on days 5 and 21.

The condition of the lesion was monitored by conducting an MRI study in standard modes, T2 VI mode with free fluid suppression (FLAIR), diffusion (DV-MRI) and perfusion-weighted (PV-MRI) MRI studies - both on admission and dynamics on days 5 and 21 in the modes FLAIR, DV-MRI, PV-MRI (tomograph Symphony, Siemens, Germany, 1.5 T).

The power of diffusion weighing with DV-MRI was b-value = 0, 500, 1000, with the subsequent automatic construction of maps of the measured diffusion coefficient (ICD), which quantitatively reflects the speed of the diffusion processes. The calculation of the size of the damage on a DV-MRI was performed according to the images obtained at b-value = 1000. PV-MRI was performed with a bolus of paramagnetic contrast medium at a rate of 5 ml / min.

Post-processing of PV-MRI data was carried out with the construction and subsequent analysis of the sizes of areas with impaired blood flow using the rCBV (relative cerebral blood volume), rCBF (relative cerebral blood flow), MTT (mean transit time), TTP (time-to-peak) maps.

The calculation of the volume of the hypoperfusion zone was performed using the MTT map. For a more accurate assessment of the size of damage according to standard modes, including determining the final size of a heart attack, the FLAIR mode was used.

Table 1
Characteristics of the group examined. Characteristic Median [IQR] The number of patients, n 25 Age years 62 The time of the MRI scan, the hours from the onset of the stroke 23.5 NIHSS stroke severity 5 Start time of the NES, hours from the moment of the onset of the stroke (only for the main group) 23

Data processing was carried out using the STATISTICA 6.0 application software package. Data are presented as medians.

The average time for the first MRI scan was 23.5 hours from the start of the II. Damage size according to standard modes, FLAIR, DVI and various PVI cards (Table 2).

21 days after the treatment, a comparison was made of the dynamics of patient recovery according to the NIHSS scale, as well as MRI data on the size of the lesion in the main and control groups (Table 2).

table 2
MRI data. Characteristic Main group Control group Mann-Whiney test, p-value Number of patients eleven fourteen MRI time (from the beginning of the stroke, h) 22 34 0.556 Damage volume by DV-MRI before treatment, cm 14,4 13.0 0.699 Damage volume according to PV-MRI before treatment, cm 76.2 55.1 0.958 The final size of a heart attack, cm 8.0 16.6 0.797 NIHSS, in points before treatment 8.5 5 0.678 after treatment 2.5 one 0.041

A positive effect of neuromuscular electrical stimulation on the restoration of neurological status in patients was found.

Analysis of the obtained MRI data showed that there is no significant difference in the evolution of the focus of acute ischemic damage in patients of the main and control groups. The size of the zone of bioenergetic disturbances in the studied groups was comparable, the same was noted with respect to the volume of hypoperfusion zones. The final size of the heart attack, despite the early activation of patients - in the acute period of AI - did not differ. By comparing the initial MRI data with the data after the treatment, the effect of the treatment factor, including non-drug, on the site of acute ischemic damage is assessed in two groups.

Thus, neuromuscular electrical stimulation of the paretic limb in the acute period of AI does not lead to a deterioration in the perfusion characteristics of the brain, as well as to the expansion of the zone of bioenergetic disorders. This allows you to introduce the applied methodology into everyday practice.

This method allows you to increase the effectiveness of rehabilitation measures currently used in the acute period of ischemic stroke, which will certainly affect the degree of motor and functional recovery of post-stroke patients.

Claims (1)

A method of rehabilitation and evaluation of its effectiveness in patients with an acute period of ischemic stroke by applying drug therapy under the control of the condition of the focus of ischemic damage using magnetic resonance imaging (MRI) by assessing the bioenergetic status of the focus, its size and state of cerebral circulation in dynamics, characterized in that, at the same time, non-drug therapy is simultaneously performed using ischemic lesion at the end of the acute period to study the focal point of the MRI regimen with p the pressure signal from the free liquid and begins to conduct MRI in patients with the first two days of the date of ischemic stroke.