Альманах клинической медицины. 2015; : 22-28
НЕЙРОМОНИТОРИНГ ПАЦИЕНТОВ С ВНУТРИЧЕРЕПНЫМИ НЕТРАВМАТИЧЕСКИМИ КРОВОИЗЛИЯНИЯМИ
https://doi.org/10.18786/2072-0505-2015-39-22-28Аннотация
Актуальность. Обследование пациентов с нетравматическими внутричерепными кровоизлияниями (НВК) с использованием пролонгированного мониторинга электроэнцефалограммы (ЭЭГ) позволяет более эффективно выявлять наличие острых симптоматических приступов, субклинической эпилептиформной активности, очаговых и диффузных нарушений, служащих маркером функциональной активности головного мозга.
Цель – повышение эффективности лечения пациентов с НВК.
Материал и методы. Обследованы 33 пациента в остром периоде НВК. Проведены клинический и неврологический осмотр; оценка состо яния по шкалам NIHSS (шкала тяжести инсульта Национального института здоровья CША), GCS (шкала комы Глазго), HHS (шкала Ханта – Хесса); пролонгированный мониторинг ЭЭГ с использованием рентгеновскoй компьютерной томографии и/или магнитно-резонансной томографии головного мозга. Применялось консервативнои хирургическое лечение (малоинвазивные эндоваскулярные вмешательства или открытые операции – клипирование и окутывание аневризм).
Результаты. Прооперированы 27 пациентов путем открытого хирургического вмешательства (из них клипирование аневризмы проведено у 23 пациентов, окутывание аневризмы – у 4). Двум пациентам выполнена эмболизация аневризм. Четыре пациента получали консервативную терапию. По результатам проведения пролонгированного до-, пери- и послеоперационного мониторирования ЭЭГ у большинства обследованных выявлены дезорганизация электрической активности, отсутствие региональных различий, фрагментация или полное отсутствие альфа-ритма, диффузно регистрируемая полиморфная тета-активность. Выраженные изменения на ЭЭГ коррелировали с тяжестью состояния по оценочным шкалам и исходом заболевания. В ходе исследования у 1 пациента зарегистрирована эпилептиформная активность, у 3 – ЭЭГ комы, у 15 – диффузные нарушения, у 14 – региональные нарушения.
Заключение. Применение пролонгированного ЭЭГ-мониторинга в пред-, пери- и послеоперационном периоде позволяет своевременно обнаруживать у пациентов эпилептический статус, в том числе бессудорожный. У пациентов с НВК проведенные в срок малоинвазивные вмешательства ассоциируются с лучшим прогнозом, а выраженные нарушения ЭЭГ – с низкими баллами по шкалам и неблагоприятным исходом заболевания. При локальных поражениях головного мозга у пациентов с сохранным сознанием ЭЭГ не обладает существенным топическим значением.
Список литературы
1. Штульман ДР, Левин ОС. Неврология: Справочник практического врача. М.: МЕД- пресс-информ; 2012. 1036 с. Shtul'man DR, Levin OS. Nevrologiya: Spravochnik prakticheskogo vracha [Neurology: reference book for a practicing doctor]. Moscow: MEDpress-inform; 2012. 1036 p. (in Russian).
2. Broderick JP, Brott T, Tomsick T, Miller R, Huster G. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg. 1993;78(2):188–91.
3. Garcia-Alvarez M, Nordli DR, De Vivo DC. Inherited metabolic disorders. In: Engel J, Pedley TA, editors. Epilepsy: a comprehensive textbook.
4. Philadelphia: Lippincott-Raven; 1998. p. 2547–62.
5. Gilmore RL. Seizures associated with non-neurologic medical conditions. In: Wyllie E, editor. The treatment of epilepsy: principles and practice. Baltimor: Williams & Wilkins; 1996. p. 654–65.
6. Сараджишвили ПМ, Геладзе ТШ. Эпилепсия. М.: Медицина; 1977. 302 с. Saradzhishvili PM, Geladze TSh. Epilepsiya [Epilepsy]. Moscow: Meditsina; 1977. 302 p. (in Russian).
7. Bateman BT, Claassen J, Willey JZ, Hirsch LJ, Mayer SA, Sacco RL, Schumacher HC. Convulsive status epilepticus after ischemic stroke and intracerebral hemorrhage: frequency, predictors, and impact on outcome in a large administrative dataset. Neurocrit Care. 2007;7(3):187–93.
8. Котов АС, Рудакова ИГ. Эпилепсия у пожилых. Журнал неврологии и психиатрии им. С.С. Корсакова. 2011;111(7):4–7. Kotov AS, Rudakova IG. Epilepsiya u pozhilykh [Epilepsy in elderly]. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2011;111(7):4–7 (in Russian).
9. Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62(10):1743–8.
10. Pandian JD, Cascino GD, So EL, Manno E, Fulgham JR. Digital video-electroencephalographic monitoring in the neurological-neurosurgical intensive care unit: clinical features and outcome. Arch Neurol. 2004;61(7):1090–4.
11. Knake S, Rochon J, Fleischer S, Katsarou N, Back T, Vescovi M, Oertel WH, Reis J, Hamer HM, Rosenow F. Status epilepticus after stroke is associated with increased long-term case fatality. Epilepsia. 2006;47(12):2020–6.
12. Knake S, Hamer HM, Rosenow F. Status epilepticus: a critical review. Epilepsy Behav. 2009;15(1):10–4.
13. Rossetti AO, Hurwitz S, Logroscino G, Bromfield EB. Prognosis of status epilepticus: role of aetiology, age, and consciousness impairment at presentation. J Neurol Neurosurg Psychiatry. 2006;77(5):611–5.
14. Novy J, Rossetti AO. Oral pregabalin as an addon treatment for status epilepticus. Epilepsia. 2010;51(10):2207–10.
15. Legriel S, Mourvillier B, Bele N, Amaro J, Fouet P, Manet P, Hilpert F. Outcomes in 140 critically ill patients with status epilepticus. Intensive Care Med. 2008;34(3):476–80.
16. Legriel S, Azoulay E, Resche-Rigon M, Lemiale V, Mourvillier B, Kouatchet A, Troche G, Wolf M, Galliot R, Dessertaine G, Combaux D, Jacobs F, Beuret P, Megarbane B, Carli P, Lambert Y, Bruneel F, Bedos JP. Functional outcome after convulsive status epilepticus. Crit Care Med. 2010;38(12):2295–303.
17. Oxbury JM, Whitty CW. Causes and consequences of status epilepticus in adults. A study of 86 cases. Brain. 1971;94(4):733–44.
18. Scholtes FB, Renier WO, Meinardi H. Generalized convulsive status epilepticus: causes, therapy, and outcome in 346 patients. Epilepsia. 1994;35(5):1104–12.
19. Aranda A, Foucart G, Ducasse JL, Grolleau S, McGonigal A, Valton L. Generalized convulsive status epilepticus management in adults: a cohort study with evaluation of professional practice. Epilepsia. 2010;51(10):2159–67.
20. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE, Mamdani MB. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. 1998;339(12): 792–8.
21. Drislane FW, Blum AS, Lopez MR, Gautam S, Schomer DL. Duration of refractory status epilepticus and outcome: loss of prognostic utility after several hours. Epilepsia. 2009;50(6): 1566–71.
22. Rossetti AO, Logroscino G, Bromfield EB. Refractory status epilepticus: effect of treatment aggressiveness on prognosis. Arch Neurol. 2005;62(11):1698–702.
23. Rossetti AO, Milligan TA, Vulliemoz S, Michaelides C, Bertschi M, Lee JW. A randomized trial for the treatment of refractory status epilepticus. Neurocrit Care. 2011;14(1):4–10.
24. Mayer SA, Claassen J, Lokin J, Mendelsohn F, Dennis LJ, Fitzsimmons BF. Refractory status epilepticus: frequency, risk factors, and impact on outcome. Arch Neurol. 2002;59(2):205–10.
25. Елфимов АВ, Спирин НН, Сковородников БИ, Иванов АО, Соловьев МВ, Введенский ВП, Малахов НВ. Анализ результатов хирургического лечения инсультных внутримозговых гематом. Нейрохирургия. 2008;(2):25–30. Elfimov AV, Spirin NN, Skovorodnikov BI, Ivanov AO, Solov'ev MV, Vvedenskiy VP, Malakhov NV. Analiz rezul'tatov khirurgicheskogo lecheniya insul'tnykh vnutrimozgovykh gematom [Analysis of results of surgical treatment of intracranial stroke hematomas]. Neyrokhirurgiya. 2008;(2):25–30 (in Russian).
26. Nakano T, Ohkuma H, Ebina K, Suzuki S. Neuroendoscopic surgery for intracerebral haemorrhage – comparison with traditional therapies. Minim Invasive Neurosurg. 2003;46(5):278–83.
27. Белова ЮА, Рудакова ИГ, Котов АС, Котов СВ. Эффективность лечения фокальной эпилепсии у больных, перенесших инсульт. Клиническая геронтология. 2014;20(7–8):55. Belova YuA, Rudakova IG, Kotov AS, Kotov SV. Effektivnost' lecheniya fokal'noy epilepsii u bol'nykh, perenesshikh insul't [Effectiveness of treatment of focal epilepsy in patients with stroke]. Klinicheskaya gerontologiya. 2014;20(7–8):55 (in Russian).
Almanac of Clinical Medicine. 2015; : 22-28
NEUROMONITORING IN PATIENTS WITH INTRACRANIAL NONTRAUMATIC HEMORRHAGE
https://doi.org/10.18786/2072-0505-2015-39-22-28Abstract
Background: Investigation of patients with intracranial non-traumatic hemorrhage (INH) with the use of prolonged electroencephalographic (EEG) monitoring allows for more effective identification of acute symptomatic seizures, subclinic epileptiform activity, local and diffuse abnormalities that are markers of brain functional activity.
Aim: To increase treatment efficacy of patients with INH.
Materials and methods: Thirty three patients were assessed in acute period of INH. Assessments included clinical and neurological examination, NIHSS (National Institute of Health Stroke Severity scale), GCS (Glasgow coma scale), HHS (Hunt-Hess scale); prolonged EEG monitoring with computerized tomography and/or magnetic resonance imaging of the brain. Patients received medical and surgical treatment (minimally invasive endovascular interventions or open operations, such as aneurysm clipping or wrapping/coating).
Results: Twenty seven patients had open-type surgeries (among them, 23 patients had aneurysm clipping and 4, aneurysm wrapping). Two patients underwent the procedure of aneurysm embolization. Four patients were treated conservatively. According to results of prolonged pre-, peri- and postoperative EEG monitoring, most of patients had signs of disorganized electrical activity, with no regional differences, fragmented or absent alfa rhythm and diffuse polymorphic theta-activity. Marked EEG abnormalities correlated with severity registered with the assessment scales and with outcomes. During the study, epileptiform activity was registered in 1 patient, EEG comate in 3, diffuse abnormalities in 15 and local abnormalities in 14.
Conclusion: The use of prolonged pre-, peri- and postoperative EEG monitoring allows for timely identification of status epilepticus, including the one without seizures. Minimally invasive interventions performed on time are associated with better prognosis in INH patients, whereas marked EEG abnormalities are associated with low scores of the assessment scales and adverse outcomes. In conscious patients with local brain lesions EEG does not have any significant value for topical diagnostics.
References
1. Shtul'man DR, Levin OS. Nevrologiya: Spravochnik prakticheskogo vracha. M.: MED- press-inform; 2012. 1036 s. Shtul'man DR, Levin OS. Nevrologiya: Spravochnik prakticheskogo vracha [Neurology: reference book for a practicing doctor]. Moscow: MEDpress-inform; 2012. 1036 p. (in Russian).
2. Broderick JP, Brott T, Tomsick T, Miller R, Huster G. Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage. J Neurosurg. 1993;78(2):188–91.
3. Garcia-Alvarez M, Nordli DR, De Vivo DC. Inherited metabolic disorders. In: Engel J, Pedley TA, editors. Epilepsy: a comprehensive textbook.
4. Philadelphia: Lippincott-Raven; 1998. p. 2547–62.
5. Gilmore RL. Seizures associated with non-neurologic medical conditions. In: Wyllie E, editor. The treatment of epilepsy: principles and practice. Baltimor: Williams & Wilkins; 1996. p. 654–65.
6. Saradzhishvili PM, Geladze TSh. Epilepsiya. M.: Meditsina; 1977. 302 s. Saradzhishvili PM, Geladze TSh. Epilepsiya [Epilepsy]. Moscow: Meditsina; 1977. 302 p. (in Russian).
7. Bateman BT, Claassen J, Willey JZ, Hirsch LJ, Mayer SA, Sacco RL, Schumacher HC. Convulsive status epilepticus after ischemic stroke and intracerebral hemorrhage: frequency, predictors, and impact on outcome in a large administrative dataset. Neurocrit Care. 2007;7(3):187–93.
8. Kotov AS, Rudakova IG. Epilepsiya u pozhilykh. Zhurnal nevrologii i psikhiatrii im. S.S. Korsakova. 2011;111(7):4–7. Kotov AS, Rudakova IG. Epilepsiya u pozhilykh [Epilepsy in elderly]. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2011;111(7):4–7 (in Russian).
9. Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62(10):1743–8.
10. Pandian JD, Cascino GD, So EL, Manno E, Fulgham JR. Digital video-electroencephalographic monitoring in the neurological-neurosurgical intensive care unit: clinical features and outcome. Arch Neurol. 2004;61(7):1090–4.
11. Knake S, Rochon J, Fleischer S, Katsarou N, Back T, Vescovi M, Oertel WH, Reis J, Hamer HM, Rosenow F. Status epilepticus after stroke is associated with increased long-term case fatality. Epilepsia. 2006;47(12):2020–6.
12. Knake S, Hamer HM, Rosenow F. Status epilepticus: a critical review. Epilepsy Behav. 2009;15(1):10–4.
13. Rossetti AO, Hurwitz S, Logroscino G, Bromfield EB. Prognosis of status epilepticus: role of aetiology, age, and consciousness impairment at presentation. J Neurol Neurosurg Psychiatry. 2006;77(5):611–5.
14. Novy J, Rossetti AO. Oral pregabalin as an addon treatment for status epilepticus. Epilepsia. 2010;51(10):2207–10.
15. Legriel S, Mourvillier B, Bele N, Amaro J, Fouet P, Manet P, Hilpert F. Outcomes in 140 critically ill patients with status epilepticus. Intensive Care Med. 2008;34(3):476–80.
16. Legriel S, Azoulay E, Resche-Rigon M, Lemiale V, Mourvillier B, Kouatchet A, Troche G, Wolf M, Galliot R, Dessertaine G, Combaux D, Jacobs F, Beuret P, Megarbane B, Carli P, Lambert Y, Bruneel F, Bedos JP. Functional outcome after convulsive status epilepticus. Crit Care Med. 2010;38(12):2295–303.
17. Oxbury JM, Whitty CW. Causes and consequences of status epilepticus in adults. A study of 86 cases. Brain. 1971;94(4):733–44.
18. Scholtes FB, Renier WO, Meinardi H. Generalized convulsive status epilepticus: causes, therapy, and outcome in 346 patients. Epilepsia. 1994;35(5):1104–12.
19. Aranda A, Foucart G, Ducasse JL, Grolleau S, McGonigal A, Valton L. Generalized convulsive status epilepticus management in adults: a cohort study with evaluation of professional practice. Epilepsia. 2010;51(10):2159–67.
20. Treiman DM, Meyers PD, Walton NY, Collins JF, Colling C, Rowan AJ, Handforth A, Faught E, Calabrese VP, Uthman BM, Ramsay RE, Mamdani MB. A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group. N Engl J Med. 1998;339(12): 792–8.
21. Drislane FW, Blum AS, Lopez MR, Gautam S, Schomer DL. Duration of refractory status epilepticus and outcome: loss of prognostic utility after several hours. Epilepsia. 2009;50(6): 1566–71.
22. Rossetti AO, Logroscino G, Bromfield EB. Refractory status epilepticus: effect of treatment aggressiveness on prognosis. Arch Neurol. 2005;62(11):1698–702.
23. Rossetti AO, Milligan TA, Vulliemoz S, Michaelides C, Bertschi M, Lee JW. A randomized trial for the treatment of refractory status epilepticus. Neurocrit Care. 2011;14(1):4–10.
24. Mayer SA, Claassen J, Lokin J, Mendelsohn F, Dennis LJ, Fitzsimmons BF. Refractory status epilepticus: frequency, risk factors, and impact on outcome. Arch Neurol. 2002;59(2):205–10.
25. Elfimov AV, Spirin NN, Skovorodnikov BI, Ivanov AO, Solov'ev MV, Vvedenskii VP, Malakhov NV. Analiz rezul'tatov khirurgicheskogo lecheniya insul'tnykh vnutrimozgovykh gematom. Neirokhirurgiya. 2008;(2):25–30. Elfimov AV, Spirin NN, Skovorodnikov BI, Ivanov AO, Solov'ev MV, Vvedenskiy VP, Malakhov NV. Analiz rezul'tatov khirurgicheskogo lecheniya insul'tnykh vnutrimozgovykh gematom [Analysis of results of surgical treatment of intracranial stroke hematomas]. Neyrokhirurgiya. 2008;(2):25–30 (in Russian).
26. Nakano T, Ohkuma H, Ebina K, Suzuki S. Neuroendoscopic surgery for intracerebral haemorrhage – comparison with traditional therapies. Minim Invasive Neurosurg. 2003;46(5):278–83.
27. Belova YuA, Rudakova IG, Kotov AS, Kotov SV. Effektivnost' lecheniya fokal'noi epilepsii u bol'nykh, perenesshikh insul't. Klinicheskaya gerontologiya. 2014;20(7–8):55. Belova YuA, Rudakova IG, Kotov AS, Kotov SV. Effektivnost' lecheniya fokal'noy epilepsii u bol'nykh, perenesshikh insul't [Effectiveness of treatment of focal epilepsy in patients with stroke]. Klinicheskaya gerontologiya. 2014;20(7–8):55 (in Russian).
