Procjena vrijednosti određivanja CO2 reaktivnosti moždanih arterija transkranijskim Dopplerom u infekcijama središnjeg živčanog sustava

Lepur, Dragan (2010) Procjena vrijednosti određivanja CO2 reaktivnosti moždanih arterija transkranijskim Dopplerom u infekcijama središnjeg živčanog sustava. PhD thesis, Sveučilište u Zagrebu.

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Abstract

AIM AND PURPOSE OF STUDY The objective of this prospective study was to assess the association between cerebral CO2 reactivity (CO2R) in patients with CNS infections and the severity, etiology and outcome of the disease. An additional objective was to assess the prognostic value of CO2 reactivity in these patients. The purpose of the study was to create a symptomatic treatment algorithm. EXAMINEES AND METHODS Sixty-eight patients with CNS infection and 30 healthy volunteers aged 18 years and more were included in this prospective study. The study was performed at the University Hospital for Infectious Diseases "Dr. Fran Mihaljević" in Zagreb. Observational period was between January 2005 and May 2009. CO2 reactivity was measured by using a transcranial Doppler ultrasound (TCD) and "breath-holding" method. TCD measurement of CO2 reactivity (CO2 R) was performed by using a Multidop 4 X (DWL, Sipplingen, Germany) with two 2-MHz pulsed wave probes 1.7 cm in diameter. The software used was TCD-8 for MDX (Version 8.0, Aaslid Rune). The probes were secured to the head of the patient with a specially designed spectacle frame. The mean blood flow velocities (MBFV) were continuously recorded during normal ventilation and during the intervention (induced hypercapnia). The breath-holding index (BHI) was calculated by dividing the percentage of MBFV increase during breath holding by the duration of apnea (in seconds) in both middle cerebral arteries (MCA) and the average index (BHIm) was noted. RESULTS Advanced age (52 vs 37 years, p=0,002), lower GCS (7,5 vs 15, p<0,001) and mechanical ventilation (87,5% vs 32,1% ; p <0,001) were associated with impaired cerebral vasoreactivity (BHIm <1,18). Unfavorable outcome (GOS 1-3) was found in 28 (41,1%) patients. In this group, BHIm was significantly lower compared to the favorable group (0,835 vs 1,285). Comparison of BHIm between bacterial and non-bacterial groups according to the outcomes of disease showed no differences (p=0,460). Logistic regression analysis revealed that impaired CO2R was independently associated with unfavorable outcome (OR=4,922; 95%CI 1,161-20,875). CONCLUSION CO2R was confirmed as a reliable indicator of disease severity and a valuable prognostic factor in infections of the CNS. The etiology of disease (bacterial vs non-bacterial) showed no association with CO2R.

Abstract in Croatian

CILJEVI I SVRHA RADA Cilj ove prospektivne studije bio je utvrditi povezanost CO2 reaktivnosti (CO2R) moždanih arterija s težinom upalnih bolesti CNS-a, njihovim ishodom te etiologijom bolesti. Nadalje, jedan od ciljeva bio je odrediti i prognostički značaj CO2 reaktivnosti u tih bolesnika. Svrha disertacije izrada je postupnika za simptomatsko liječenje bolesnika s infekcijama CNS-a. ISPITANICI I METODE U studiju je uključeno 68 bolesnika s upalnim bolestima CNS-a i 30 zdravih dragovoljaca u dobi od 18 i više godina hospitaliziranih u Klinici za infektivne bolesti ‘Dr.Fran Mihaljević’ u periodu od siječnja 2005. do svibnja 2009. godine. CO2 reaktivnost moždanih arterija ispitivana je transkranijskim Dopplerom s "breath-holding" metodom. Mjerenja su vršena pomoću 'Multidop X 4' aparata (DWL Electronische Systeme GmbH, Sipplingen, Njemačka) s dvije sonde od 2 MHz promjera 1.7 cm. Upotrijebljen je software ‘TCD-8 for MDX v. 8.0’ (Aaslid Rune). Sonde su fiksirane pomoću originalnog nosača. Srednje brzine strujanja krvi (MBFV) kontinuirano su snimane tijekom normalne ventilacije odnosno tijekom intervencije (inducirana hiperkapnija). Izračunat je ''breath-holding indeks" (% povećanja MBFV/sekunde apnoje) pomoću tabličnog kalkulatora za obje srednje moždane arterije (MCA) i bilježena je srednja vrijednost (BHIm). REZULTATI Bolesnici s reduciranom CO2R značajno su stariji (52 prema 37 godina, p=0,002), dublje poremećene svijesti (GCS 7,5 prema 15, p<0,001) i češće mehanički ventilirani (87,5% prema 32,1% ; p <0,001). Nepovoljni ishod bolesti (GOS 1-3) zabilježen je kod 41,1% (28/68) bolesnika. U toj skupini BHIm značajno je niži (0,835 prema 1,285) u usporedbi sa skupinom povoljnog ishoda. Usporedbom skupina s bakterijskim i nebakterijskim upalnim bolestima CNS-a nije nađena razlika u CO2R s obzirom na ishod bolesti (p=0,460). Logističkom regresijskom analizom utvrđeno je kako je reducirana CO2R prediktor nepovoljnog ishoda (OR=4,922; 95%CI 1,161-20,875). ZAKLJUČAK CO2R pouzdani je indikator težine bolesti i dobar prediktor ishoda bolesti. Etiologija upalnih bolesti CNS-a (bakterijske prema nebakterijskim) nije povezana s promjenama u CO2R.

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