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621. Иванов Г.Г., Балуев Э.П., Петухов А.Б., Ни- состава тела. Вестник РУДН. Медицина. 2000. Вып. колаев Д.В. Биоимпедансный метод определения 3. С 66-73.
THE INDICES OF EVOKED BRAIN POTENTIALS IN DYNAMIC FOLLOW-UP IN PATIENTS WITH BRAIN CONCUSSION
Zhukovskyi О.О.
Higher State Educational Establishment of Ukraine "Bukovinian State Medical University ", Chernivtsi ABSTRACT
The thesis presents the results of visual, brainstem auditory and cognitive evoked potentials testing in patients with brain concussion in the first 24 hours after head trauma and in dynamic follow-up on the 5th and the 10th day after mild traumatic brain injury.
Keywords: brain concussion, evoked potentials.
Background. Traumatic brain injury (TBI) is one of the most actual problems in neurology and neurosurgery. The estimated annual incidence of TBI in different regions of Ukraine varies from 1.6 to 4.0 per 1000 population. The most frequent type of head trauma is mild TBI which accounts for 70-80% of all TBI cases. For a long period of time mild TBI had been underestimated as it remained in the shadow of more dramatic severe head injury. However the high prevalence of not only mild TBI but also of its consequences turns it into independent medical and social problem requiring special attention.
Brain concussion is the mild forms of TBI which are characterized by short-term reversible impairment of neurological functions, so objective diagnostic methods for mild TBI need further study and improvement.
One of the possible pathophysiological mechanisms of traumatic brain damage is diffuse axonal injury. Head trauma is followed by brain motion in cranial cavity and acceleration/deceleration or rotational injuries of axons. More mobile cerebral hemispheres move ("twist") against relatively fixated brain stem. This leads to stretching and torsion of long axons which connect brain cortex and subcortical structures with brain stem. It immediately violates the function of ascending activating reticular formation and results in loss of consciousness. In case of mild TBI this process is restricted to invertible disturbance of axonal function.
Taking into consideration that there are particularly no signs of organic lesion in mild TBI, it is important to diagnose this pathology with the method that characterizes the functional state of neuronal pathways and allows for more precise localization of traumatic damage. Thus, evoked potentials (EPs), or evoked responses can help in assessment of higher cortical functions impairment in patients with brain concussion.
The aim of research. In our study we aimed to determine the dynamics of visual, brainstem auditory and cognitive EPs in patients with brain concussion. Materials and methods. We have examined 24 patients with mild TBI aged 19-45 years, including 5 women and 19 men. The causes of trauma in most cases were intentional injuries and motor vehicle collisions. All patients were examined thrice: during the first 24 hours after head trauma, on the 5th day after trauma, and after treatment period (on the average the 10th day after
injury). The fifth day was chosen according to the current concepts of pathogenesis of mild TBI which state that metabolic changes in the brain are critical in this period. The basic therapy of TBI included standard prescription of analgesics, sedatives, nootropic drugs, and diuretics.
The results of patients with trauma were compared to the control group which comprised 15 practically healthy individuals comparable by age and sex.
EP testing was performed on multifunctional computerized complex "Neuro-MVP". Visual EPs were tested with flash stimulation (1 Hz stimulus rate) and checkerboard pattern with rectangle shape of stimulus. Brainstem auditory EPs were recorded in a 2-channel montage with a sound signal of 85 dB. For cognitive EPs examination we used "significant" stimuli, e.g. signals with frequency rate 2000 Hz and probability of delivery up to 30%, as well as non-significant stimuli with frequency rate 1000 Hz and probability of delivery from 70%. Electrodes were placed according to international scheme "10-20". All components of EPs were separated and marked according to standard criteria accepted in neurophysiology. The results were assessed by the shape of the curve, the presence of all components, indexes of latent periods and the amplitudes of potential components. The data were evaluated statistically with Student's t-test (significance level a=0.05).
Results and discussion.
The results from the analyses of visual EPs in response to flash of light the first 24 hours after head trauma have shown statistically significant elongation of the approximate peak latency of the late component in patients with brain concussion (p<0.05). The existing data suggest that the late components of visual EPs are generated by the afferent inflow from reticular formation, thalamic nuclei, mediobasal parts of limbic cortex of temporal and frontal lobes. The late components of visual EPs with approximate peak latency more than 100 ms comprise non-specific component of response. Taking into account their high sensitivity to alterations of consciousness, attention, emotional state, functional activity of brain, we may conclude that our patients with mild TBI had changes in limbic-reticular system of brain. The shape of the curve of visual EPs was characterized by confluence of the late components N2, P3, N3 into one continuous negative wave. The P4 and N4 components were not taken into consideration because of their inconstancy and optionality in visual
10% patients with brain concussion substantial improvement was not observed.
The results of visual EPs assessment are presented in Table 1.
EPs examination. No disturbances of latent periods and amplitude changes of early and middle components (they reflect visual nerves conductivity) were found.
On the 5th day after brain concussion the visual EPs patterns have demonstrated gradual decrease of duration of the latent period. After the course of treatment the latency of the late components of visual EPs approximated to the normal levels (p>0.05). However in
Table 1
Peak latency of the late components of visual evoked potentials after mild traumatic brain injury (ms)
1st day 5th day After treatment (10th day)
Component BC Control group BC Control group BC Control group
N2 153.4+2.9 p<0.05 128.5+3.4 143.3+3.7 p<0.05 128.5+3.4 135.4 +3.6 p>0.05 128.5+3.4
P3 179.3+3.3 p<0.05 162.7+2.8 175.3+3.6 p<0.05 162.7+2.8 165.3+3.7 p>0.05 162.7+2.8
N3 189.5+2.8 p<0.05 174.3+3.2 183.4+3.3 p>0.05 174.3+3.2 179.9+3.5 p>0.05 174.3+3.2
BC - patients with brain concussion; p - significance of differences in comparison with control group.
For evaluation of the functional state of the brain stem we have used the method of brainstem acoustic EPs. Normal acoustic EPs consist of 5-7 peaks. The first two peaks are peripheral and they reflect the condition of distal and proximal parts of acoustic nerve. The rest of components are generated by brainstem structures. Examination of brainstem acoustic EPs in patients with mild TBI has not revealed any statistically significant differences in latent periods of components in comparison to the corresponding indexes in healthy individuals (p>0.05). The analysis of data in dynamic observation has not shown any pathological deviations in patients with brain concussion.
The results of our study are not contrary to the current opinion about pathogenesis of mild TBI, and particularly of the theory of diffuse axonal injury when the pathological changes involve only long axons and do not affect fixated brain stem. It should be also considered that brainstem acoustic EPs reflect the function of conducting sound on a rather limited area. Lesions of the other levels of brain stem may not substantially influence the values that are measured in the present study.
In clinical presentation of mild TBI cognitive impairment is one of the leading manifestations. However, the presence and the level of severity of cognitive impairment are rather hard to determine.
Aiming to assess the state of higher cerebral functions we used the method of detection of cognitive EPs which are related to thinking. This technique is based on the appearance of the late component P300 with approximate peak latency about 300 ms. This component on the potential curve is connected with recognition, memorization and estimation of stimuli.
The analysis of cognitive EPs in the first 24 hours of head trauma in patients with brain concussion and mild brain contusion has demonstrated statistically significant elongation of P300 latency (p<0.05). These changes indicate disturbances of higher cerebral functions id patients with TBI. We consider elongation of P300 latency and decrease of it's amplitude as a sensitive indicator of cognitive impairment in patients with mild neurotrauma. The changes of cognitive EPs is related to difficulties in differentiation and recognition of signals, violation of the mechanisms of operative memory, directed attention and increased patient distraction.
Table 2
P300 latency after mild traumatic brain injury (ms)
Component 1-st day 5-th day After treatment Control group
P300 325.6+2.3 p<0.05 332.3+3.6 p<0.05 318.4+3.4 p<0.05 328.1+4.6 p<0.05
BC - patients with brain concussion; p - significance of differences in comparison with control group.
On the 5th day after head trauma in patients with brain concussion we have observed an increment of P300 latency. In our opinion the underlying cause of these changes is a gradual destructive process in nervous tissue resulting from trauma. After the course of treatment on the 10th day of mild TBI the P300 latency has shown the tendency to decrease. Despite the posi-
tive dynamics in these groups, P300 values after treatment were higher in comparison to control group (p<0.05). The indexes of P300 latency can be considered as the objective criterion of treatment efficacy of cognitive impairment.
Conclusions. 1. Evaluation of visual EPs in the first 24 hours of mild TBI has shown statistically significant elongation of the latency of late components of visual EPs with the further regress of these values.
2. Assessment of the brainstem acoustic EPs in patients with mild TBI has not shown any changes in EPs pattern.
3. According to the results of cognitive EPs testing the most pronounced impairment of higher cerebral functions in patients with brain concussion was observed on the 5th day after head injury.
References
1. Алексеенко, Ю.В. Изменения когнитивных потенциалов Р300 в оценке нарушений функционального состояния центральной нервной системы у больных с сотрясением головного мозга / Ю.В. Алексеенко //Мед. новости. - 2002. - .№3. - С.66-68.
2. Гнездицкий В.В. Вызванные потенциалы мозга в клинической практике / Гнездицкий В.В. -Таганрог: Изд-во Таганрогского государственного радиотехнического университета, 1997. - 252 с.
3. Дзяк, Л.А. Посттравматические мнестиче-ские нарушения / Л.А. Дзяк, Е.В. Мизякина, А.И. Павлов // Международный неврологический журнал. - 2011. - № 8. - С. 76-82.
4. Крылов В., Лебедев В. Черепно-мозговая травма / В. Крылов, В. Лебедев //Врач. - 2000. -№11. - С.13-18.
5. Обухова, О.В. Лёгкая черепно-мозговая травма и её последствия / О.В. Обухова, Д.Р. Штульман // Рос. мед. ж. - 2001. - №3. - С.41-44.
6. Педаченко, £.Г. Черепно-мозкова травма: принципи невщкладно! допомоги, стандарта дiагностики та лшування / £.Г. Педаченко //Шку-вання та дiагностика. - 2000. - №1. - С.31-34.
ПОР1ВНЯЛЬНИЙ АНАЛ1З ЯКОСТ1 ЖИТТЯ, ПОВЯЗАНО1 З ГЕМОФ1Л1СЮ А, У Д1ТЕЙ В УКРА1Ш ТА еВРОПЕЙСЬКИХ КРА1НАХ
Маркт А.1.
астрант кафедри nediampii i неонатологи ФПДО Львiвський нацюнальний медичний yHieepcumem iMeHi Данила Галицького
м. Львiв, Украша
COMPARATIVE ANALYSIS ON THE HEMOPHILIA-A-RELATED QUALITY OF LIFE OF CHILDREN IN UKRAINE AND EUROPEAN COUNTRIES
Markin A.I.
PhD student of the Department ofpediatrics and neonatology FPGE Danylo Halytskyi Lviv National Medical University
Lviv, Ukraine
АНОТАЦ1Я
Мета: провести порiвняльний аналiз якосп життя, пов'язано! з тяжкою формою гемофш! А (ЯЖ) у дтгей, м1ж Украшою та шшими кранами; встановити вiковi особливосп мiжнацiональних вщмшностей показнишв ЯЖ у рiзних сферах психосощального функщонування (ПФ) дней.
Матерiали i методи: дослщжено ЯЖ у 94 дней трьох вшових груп ( група I - 4-7р., II - 8-12р., III -13-16р.) з тяжкою формою гемофш! А (ТГА) в Укрш'ш методом сощолопчного опитування з використан-ням валвдовано! украшсько! версп опитувальника Haemo-QoL. Методом аналiзу лггератури визначено найактуальнiшi дослiдження ЯЖ у дней з ТГА, проведенi в шших державах. Проведено компаративний аналiз ЯЖ в Украiнi та шших крашах.
Результати: встановлено, що ЯЖ у дней з ТГА значно вiдрiзняeться у рiзних краiнах. Зокрема, пока-зники ЯЖ у нашому дослiдженнi у дiтей усiх вжових груп е достовiрно гiршими, як у крашах захвдно! £вропи (£К). Найгiршими, в порiвняннi з £К, е показники ЯЖ у таких сферах ПФ, як фiзичне здоров'я ( у 3,2 рази пршою) та самопочуття (у 3,8 разiв); кращою, однак лишень на 8%, ЯЖ в украшських дiтей 4-16р. в порiвняннi з £К виявлено лишень у сферi «тдтримки оточуючих». У дiтей III групи особлива рiзниця в сторону пршо1' ЯЖ в Укра!ш виявлена у ввдносинах з протилежною статтю (у 5,9 разiв).
Висновки: ЯЖ у дней з ТГА в Украiнi е значно пршою за краши захвдно! £вропи як загальна, так i в абсолютнiй бiльшостi детермiнант психосощального розвитку. Враховуючи, що ЯЖ в £К е одшею з най-кращих у свiтi, такi показники на даному iсторичному етапi можна вважати «еталонними» для Укра!ни, а виявлеш вiковi вiдмiнностi показникiв ЯЖ в окремих сегментах ПФ слад використовувати для розробки програм психосоцiальноi реабiлiтацii та пiдтримки дiтей з ТГА в Укрш'ш.
ABSTRACT
Objective: to conduct a comparative analysis of the severe haemophilia-related qyality of life (QOL) in children between Ukraine and other countries; to establish the age-related peculiarities of inter-ethnic differences in the indicators of QOL in various spheres of psychosocial functioning (PF) of children
Materials and methods: QoL was assessed by the method of a sociological survey of 94 children of three age groups (I - 4-7 years, II - 8-12 years, III - 13-16 years) with severe hemophilia A (sHA), using a validated Ukrainian version of the questionnaire Haemo-QoL. The method of analysis of literature has determined the most
