Diagnosis of cerebral edema
The invention relates to medicine, viz.neonatology and can be used to diagnose cerebral edema in newborn infants with perinatal encephalopathy of various origins. The method allows to increase the accuracy of diagnosis and simplify the diagnostic procedure. To do this, an ultrasound scan of the brain of a newborn child in the mid sagittal plane is performed. Evaluate the state of the CSF, and in the presence of echogenicity of their structure and the preservation of contours of all cerebrospinal fluidways in the investigated plane, the first degree of cerebral edema is diagnosed, in the absence of the third ventricle, the second degree of cerebral edema is diagnosed in the contours of the cerebrospinal fluid pathways, in the absence of the third and fourth ventricles and revealing the cavity of the transparent septum - the third degree of brain edema, and in the absence of the third, fourth ventricles and the cavity of the transparent septum in the contours of the cerebrospinal fluidways - the fourth degree of o the current of the brain. 1 tab.
The invention relates to medicine, namely neonatology, and can be used to diagnose cerebral edema in newborn infants with perinatal encephalopathy of various origins.
Known way to diagnose cerebral edemain newborn children by clinical signs, such as pronounced adynamia, muscle hypotension, sucking, swallowing, vomiting, convulsions, respiratory distress, hyperesthesia. The child can be excited, in these cases extensor tonus prevails. The large fontanel is tense, the cranial sutures are widened. On the eyeground, the edema of the nipple of the optic nerve. The disadvantage of the known method is the relatively low accuracy of diagnosis, which is caused by the nonspecificity of the listed signs of cerebral edema. It is known that cerebral symptomatology coincides with intracranial hemorrhage, hypoxia, edema of the brain. In addition, it is extremely difficult to differentiate the rapidly developing cerebral edema from intracranial hematoma only on the basis of data from a neurological study.
The closest to the technical entity toThe claimed solution is a method of diagnosing cerebral edema in newborn infants by means of ultrasound scanning (ultrasound) as the prototype. According to the prototype method, ultrasound is produced in longitudinal and transverse planes. The presence of pathology is established when the normal ultrasound pattern changes necessarily in two projections. Cerebral edema is diagnosed in the presence of uneven and non-synchronous pulsation of cerebral vessels, a uniform increase in total echolocation, as well as a decrease in ventricular lumen and a smoothing of the gyri. The disadvantage of the prototype method is the relatively low accuracy of diagnosis. This is due to the following: brain tissue, studied by the method of the prototype method, are normally echogenic, the pulsation of the vessels is normally determined, and the ventricles normally have a slit shape. Therefore, the lack of quantitative indicators of the degree of expression of the diagnostic criteria of the prototype method in pathology leads to the subjectivity of their evaluation, making it dependent on the experience of the researcher. In addition, the diagnostic criteria in question are ambiguous: a decrease in cerebral vascular pulsation, noted with ultrasound, may be associated with posthypoxic disorders of systemic and intracerebral circulation, a diffuse increase in cerebral tissue echo density may occur in severe hypoxic-ischemic brain lesions that are not always accompanied by its edema, with edema of the brain, the lateral ventricles may both decrease and increase, in particular, clinical Luden indicate that the size of the lateral ventricles may increase when the swelling of the brain combined with intraventricular hemorrhage. It is also possible to increase the lateral ventricles with increasing edema, especially at its extreme degrees. On the other hand, with hypoxic-ischemic, traumatic encephalopathy, not accompanied by the development of cerebral edema, the size of the lateral ventricles may decrease due to a reduction in the production of cerebrospinal fluid by the plexus of the lateral ventricles. The prototype method also does not allow to determine the degree of cerebral edema, the dynamics of its development, which makes it impossible to perform differentiated degrees of treatment. In addition, the disadvantage of the prototype method is the relative complexity of the diagnostic procedure, since the need for research in two projections increases the number of structures to be examined for diagnosis.
The aim of the invention is to improve the accuracy of diagnosing cerebral edema in newborn infants and to simplify the diagnostic procedure.
The aim is achieved by the fact that in the methoddiagnostics of cerebral edema in newborns by ultrasound scanning ultrasound is performed in the middle sagittal plane, the condition of the CSF is assessed, and if there is an echogenicity of their structure, cerebral edema is diagnosed. With the preservation of contours of all cerebrospinal fluid in the investigated plane, the first degree of cerebral edema is diagnosed, in the absence of the third ventricle, the second degree of cerebral edema is diagnosed in the contours of the cerebrospinal fluidways, in the absence of the third and fourth ventricles and the presence of a pronounced cavity of the transparent septum, the third degree of cerebral edema is diagnosed, and in the absence of the third, fourth ventricles and the cavity of the transparent septum in the contours of the cerebrospinal fluid pathways, a fourth degree of cerebral edema is diagnosed.
Achieving a positive effect is due tothe following: the cerebrospinal fluid system, which is examined with ultrasound in the middle sagittal section, is normally represented by constant, clearly traced anechoic structures consisting of the third and fourth ventricles of the brain, as well as a transparent septum, which is present in 58% of the term, in premature babies 76% However, in the literature there is no information on the possibility of the appearance of echogenicity of these structures in various pathologies of the brain, including in edema. There is also no information on the possibility of using the condition of the third ventricle to diagnose cerebral edema. Most of the authors confined themselves to describing its form outside of the connection with the pathology under investigation.
In carrying out the research for the first time,that it is the echogenicity of the cerebrospinal fluid in the middle sagittal plane (the third and fourth ventricles) that is a specific sign when the brain is swollen in newborn infants. With edema of the brain in newborn infants, the contraction of the third and fourth ventricles appears, apparently, due to their compression by the edematous hemispheres of the brain. It is possible that when the brain is swollen, the lumens of the monropean openings are easily closed, and therefore the outflow of the cerebrospinal fluid from the lateral ventricles (the lateral ventricles widens) into the cavity of the third and fourth ventricles is disturbed, which leads to a further narrowing of the latter up to the complete disappearance of their lumen. With edema of the brain in newborns, accompanied by intraventricular hemorrhage, when the lateral ventricles widen, the third and fourth ventricles nevertheless remain narrowed, since the blood in them can either not come at all due to compression of the monorhoeal orifices, or it is displaced by the edematous brain into the lower parts liquor system through the open Sylvia aqueduct, the holes of Lushka and Mojendi. When hypoxic-ischemic brain damage is not accompanied by the development of edema, the contraction of the third and fourth ventricles does not occur due to compression of their hemispheres of the brain, regardless of the amount of formed cerebrospinal fluid and the degree of increase or decrease of the lateral ventricles.
Condition of the third ventricleit is possible in principle to evaluate with ultrasound in the frontal and medial sagittal planes. However, the relatively large variability of the width of the third ventricle (1-4 mm) makes it difficult to use the state of this structure as a diagnostic criterion for conducting studies in the frontal plane. In addition, the presence of an intertalamic septum with ultrasound in the frontal plane in a number of cases causes the appearance of a picture of the closure of the walls of the third ventricle in the absence of cerebral edema. When examining in the middle sagittal plane, where the ventricular condition is estimated by echogenicity, the presence of an intertalamic septum does not affect the accuracy of the diagnosis of cerebral edema, since it is known that this formation is clearly visible with ventricular expansion, but it does not appear when it narrows, which is confirmed by experimental studies. The state of the lumen of the fourth ventricle can be estimated practically only in the medial sagittal plane. Thus, the echogenicity of the structure of the cerebrospinal fluid in the mid sagittal plane is a specific criterion for diagnosing cerebral edema that does not depend on the anatomical features of their structure.
It was found that with ultrasound examinationthe following regularity is observed in the dynamics of cerebral edema: in the initial stages (I-II degree) there is edema of the cerebral hemispheres, in the subsequent stages (III-IV degree) the brainstem is edema followed by its dislocation. We found a correlation between the degree of ultrasonography determined using the claimed method of cerebral edema and the depth of CNS depression in a newborn who underwent asphyxia, a birth trauma of the brain. When assessing the depth of CNS depression, the classification of Plum and Posner was used, in which four levels of impairment of consciousness were identified: lethargy, congestion, stupor and coma. This classification is also applicable to newborn babies. It was also found that, at the first degree of cerebral edema in neonates detected by ultrasound using the proposed method, there was a state of lethargy, deafness, with stupor 2 and coma, but with safety the pupil reflexes (pupillary reflex, oculocephalic reflex, corneal and proboscis reflexes), at the third degree there was a coma with severe inhibition or complete absence of the stem-level reflexes, with the IV degree of coma with no refs leksov stem level. It was also noted that in neonates with hypoxic-ischemic encephalopathy not accompanied by brain edema (according to the results of ultrasound using the claimed method), the regress of neurologic symptoms was more frequent than in the case of newborns with hypoxic-ischemic encephalopathy accompanied by cerebral edema. Apparently this is due to the fact that cerebral edema occurs more often due to necrotic damage to the brain tissue. Simplification of the diagnostic procedure is due to the fact that the study is produced in one projection, and the degree of echogenicity of only the CSF is estimated. Thus, it is the proposed set of features of the claimed solution that provides the appearance of a new property of the possibility of evaluating the specific features of the cerebral edema of newborns for the dynamics of the state of the cerebrospinal structures (third and fourth ventricles, transparent septum) irrespective of their anatomical structure.
The method is carried out as follows. Studies are conducted in patients with newborns in intensive care units, intensive care for newborns. Ultrasound scanning is performed using ultrasound devices, for example, using a portable device "Ausonics M1-1000" from Sonoregner (Australia) with a sector sensor of 5 and 7.5 MHz using a known technique. The power of ultrasonic radiation is 36 dB. Contrasting is carried out with an unclear image obtained on the screen of the device. The sensor, on the head of which is preliminarily layered with a transparent colloidal mass, is applied to the large fontanel of a newborn child in such a way that the plane of the sector of ultrasonic radiation exactly coincides with the middle sagittal plane of the head. An evaluation is made of the state of the cerebrospinal fluidways defined in this plane.
EXAMPLE 1 Patient A. history of the disease N 8148. A child from the 1st pregnancy, who had had an acute respiratory infection on the 32nd week, urgent traumatic births with the prolapse of the umbilical cord loops. Body weight at birth 3300 g, okr. head 36 cm, okr. breast 35 cm. Evaluation on the Apgar scale 1/3 point. The amniotic fluid from the tracheobronchial tree was sanitized. Resuscitation measures were carried out. Weak pods appeared on the 10th minute. In the first two days of life, the condition was regarded as very serious, was on mechanical ventilation, repeated clonic convulsions. By the end of the second day, independent breathing became adequate, was extubated.
Upon admission to the intensive care unitneonatal DHS N 1 aged 3-5 days the child's condition is severe. The deafness, for inspection, reacted with a grimace of mourning, weak movements in the limbs. Semi-flexural posture in the upper limbs, "frog pose" in the lower limbs. Weakened reflexes of newborns: sucking, grasping, reflex Babkin. The seams of the skull are not dilated, a large fontanel is made, not tense. On the 5th day of life, ultrasound scanning in the middle sagittal plane revealed the echogenicity of the third ventricle with the preservation of its contours. Diagnosis of cerebral edema of the 1 st degree. The ultrasound was performed using the prototype method: the lateral ventricles are slit, the general echogenicity of the brain is not increased, the pulsation of the vessels is determined. Thus, distinct signs of cerebral edema, determined by the prototype method, were absent in this case. With a one-dimensional ECHOEG, an increase in the number of echoes, with an EEG a decrease in bioelectrical activity. With lumbar puncture, the cerebrospinal fluid flowed with rare drops (cytosis 2/3, Protein 3.3 g / l). An ophthalmic fundus without apparent pathology. The diagnosis was: intranatal encephalopathy of hypoxic-traumatic genesis, acute period, moderate severity, CNS depression syndrome, convulsive syndrome. Treatment: nootropil, lasix (then diacarb), vitamins B6. AT1 in / m, antibiotic therapy.
The child's condition was improving. Already on the 8th day of life the following positive dynamics was noted: clear sight, motor activity significantly increased, the baby sucks well (up to 8 days of life feeding through the probe), all reflexes of newborns are called.
At repeated (on the 10th and 16th day of life)Ultrasound scanning of the brain in the middle sagittal plane is the anechoic pathways, i.e. edema of the brain regressed. At US on a method-prototype attributes of an edema of a brain were absent, lateral ventricles slit-shaped. At the age of 22 days the child was discharged home in a satisfactory condition.
EXAMPLE 2 Patient M. history of the disease N 6068. The child entered the intensive care unit of neonatal DHS N 1 15 hours after birth. The child from the 1st pregnancy, which was taking place against a background of chronic tonsillitis, influenza for 7 months. pregnancy. Childbirth at the 43rd week. In childbirth, chorioamnionitis, weakness of labor. The child is removed by cesarean section. Body weight at birth 3600 g, body length 51 cm, approx. Goal. 35 cm, the score on the Apgar scale is 2/4 points. When the trachea was sanitized, amniotic fluid with meconium was obtained. The condition from birth was severe: ventilator was carried out, oppression of reflexes was noted, pupillary reflex was sluggish. At admission: a deep stupor, independent breathing is ineffective. Reflexes of the stem level are alive (pupillary, oculocephalic, corneal, proboscis reflexes). Adynamia, posture of decortication (flexor position of the upper limbs, extensor position in the lower limbs), muscle tone varies, with a predominance of increased. Head of regular shape, a large fontanel is made, moderately tight, the seams of the skull at the junction. On the first day of life, the child had repeated tonic convulsions. On the day of admission, ultrasound scanning in the middle sagittal plane revealed an increase in the echogenicity of the third ventricle with the absence of its contours. The edema of a brain of II degree is diagnosed. With ultrasound of the brain by the prototype method, signs of cerebral edema are not convincing: the lateral ventricles are slit-shaped, the vascular plexuses are well defined, the echogenicity of the brain without a distinct increase, except for a moderate increase in echogenicity in the periventricular zone at the level of the posterior parts of the lateral ventricles, pulsation of the brain vessels was determined.
With one-dimensional Echo, many additionalechoes. On EEG decrease in bioelectrical activity of the brain. On the eyeground, the expansion of venous vessels. Diagnosed: hypoxic-ischemic severe encephalopathy, acute period, CNS depression syndrome, convulsive syndrome. The condition of the child was severe, until the 4th day of life, repeated tonic convulsions. It was carried out mechanical ventilation, dehydration therapy (mannitol, lasix), prostosudorazhnaya therapy. The UZ-study was repeated every day. On the 5th day of life, the disappearance of the echogenicity of the cerebrospinal structures during ultrasound scanning in the median sagittal plane was noted. The lateral ventricles of the brain are slit-like, the echolocation of the brain tissue is elevated in the region of the subcortical nuclei and in the periventricular zones. Pulsation of cerebral vessels is observed. On the 6th day the child's condition improved, consciousness restored, transferred to auxiliary ventilation, was extubated on the 9th day and transferred to the Neonatal Intensive Care Unit. In the future, the child showed increased excitability of the central nervous system, sleep disturbance, a syndrome of motor disorders (impairment, stiffness of movements, increased muscle tone). Ultrasound scanning revealed signs of an atrophic process in the brain in the form of an expansion of the lateral ventricles, an uneven increase in the echolocation of the brain tissue.
EXAMPLE 3 Patient P. history of the disease N 6076. A boy from IV pregnancy (3 medoborts, gonorrhea in 1983, secondary infertility), proceeding with the threat of interruption, ARVI at 16 weeks, delivery is urgent. The body weight at birth is 3410 g, the Apgar score is 1/3. Self-breathing appeared after 15 minutes. The condition was very severe, there was no reaction of the pupils to light. The transfusion of fresh frozen plasma was performed in the maternity hospital, GHB, dicinone was administered.
Enrolled in the department of resuscitation of newbornsDSB N 1 at the end of 1 day of life. The condition at admission is very severe: coma, pupils of medium size with a barely noticeable reaction to light, other stem-level reflexes and tendon reflexes were absent. Continued ventilation. The child had adynamia, atony. Sutures of the skull at the junction, large fontanel 0,8х0,8 cm.
With ultrasound scanning of the brain inmiddle sagittal section revealed increased echogenicity of the third ventricle with the disappearance of its contours, which corresponds to edema of the third degree. With ultrasound in the prototype method: the lateral ventricles of the brain are slit-shaped, difficult to trace, general echogenicity of the brain tissue without pronounced enhancement, pulsation of the cerebral vessels was noted. That is, the prototype method did not reveal a set of characteristics necessary for diagnosing cerebral edema.
With one-dimensional Echo, the appearance of additionalechoes. On the eye day, edema of the optic discs. In the future, the state of the child remained extremely difficult. There was a coma with adynamia, atony, areflexia, a large fontanel with a pronounced strain, bulging, a divergence of the sagittal seam to 0.5 cm. On the 2nd and 3rd day, ultrasound scanning in the middle sagittal section determined an increase in the echogenicity of the region of the fourth ventricle with complete disappearance of its contours, the cavity of the transparent septum is expressed. The third degree of cerebral edema is diagnosed. In ultrasound scanning by the prototype method, the lateral ventricles were expanded to 3 mm, the echogenicity of brain tissue in the thalamus region increased. Pulsation of blood vessels is hardly noticeable, i.е. not all of the listed signs confirmed cerebral edema.
On the 6th day of life with the next ultrasound scan inmiddle sagittal section revealed a sharp narrowing of the cavity of the transparent septum in the absence of contours of the third and fourth ventricles of the brain (IV degree of edema). With ultrasound by the method of the prototype: the lateral ventricles are slightly dilated, slit, moderate increase in echogenicity of the brain tissue, there are no pulsating vessels.
In the spinal cord fluid (4th day of life): cytosis 3/3, protein 1.65 g / l. A diagnosis was made: perinatal encephalopathy of a hypoxic-infectious genesis. Intrauterine infection with brain, lung, liver damage. Edema of the brain. Coma.
Treatment of cerebral edema: IVL in the intensive care mode of hyperventilation, GHB, Lasix, dexamethasone was ineffective. The child died on the 19th day of life.
With pathoanatomical dissection, the brain is swollen,enlarged in volume, extensive foci of necrosis (softening) in the subcortical zones, in places a meager purulent exudate on the surface of the cerebral hemispheres. It is assumed umbilical sepsis, histological and bacteriological research has not yet been completed.
Using the claimed method,24 newborns with encephalopathy were examined. Studies were performed on the day of admission to the clinic. In addition, in a number of cases, the study of newborns was carried out in dynamics. The presence or absence of cerebral edema was established by the control complex examination (clinical signs, EEG, EchoEG), as well as the results of postmortem dissection. In parallel, these children were examined using the prototype method. The results are shown in the table.
It can be seen from the table that when usingof the claimed method, the diagnosed cerebral edema in all cases (12 newborns) was confirmed by the results of the control complex examination. Using the prototype method in 6 cases (25%), there was a hyperdiagnosis, as the results of the control complex examination indicated the presence of hypoxic-ischemic encephalopathy, not accompanied by edema of the brain, which refuted the data of the prototype method. In 7 cases (29%) there was a hypodiagnosis, as the data obtained by the prototype method did not allow to reveal cerebral edema, whereas the results of the control complex examination confirmed the presence of edema. The results shown in the table show that using the claimed method, the diagnostic accuracy is increased by 54%. Thus, the use of the claimed method provides an improvement in diagnostic accuracy of 54% and a simplification of the diagnostic procedure in comparison with the prototype method due to the possibility of assessing the edema-specific headache brain neonatal features of the dynamics of the state of the cerebrospinal structures (third and fourth ventricles, transparent septum) regardless of their anatomical structure. Isolation of degrees of edema with the use of the claimed method makes it possible to determine the dynamics of cerebral edema development, which makes it possible to perform differentiated degrees of treatment.
METHOD OF DIAGNOSTICS OF THE HEART BRAIN TOWERNewborn children by ultrasound scanning, characterized by the fact that the scan is performed in the middle sagittal plane, the state of the structures of the cerebrospinal tract is evaluated and, if their echogenicity is detected and the contours of the cerebrospinal tract are detected, the first degree of cerebral edema is diagnosed, in the absence of the third ventricle in the contours of the cerebrospinal fluid pathways, the second degree, the absence of contours of the third and fourth ventricles and the detection of the cavity of the transparent septum, the third degree, in the absence of the third, fourth ventricle cavity and brain in a transparent partition in the circuits liquor flows fourth degree of cerebral edema.