DIFFICULTIES IN EARLY REHABILITATION OF THE PATIENT THE RECOVERY PERIOD OF A CEREBRAL INFARCTION AGAINST THE BACKGROUND OF A POSTPONED CORONAVIRUS INFECTION
- Authors: Bedirov M.D.
- Issue: Vol 10 (2021): Материалы XVII Международной Бурденковской научной конференции 22-24 апреля 2021 года
- Pages: 257-260
- Section: Неврология
- URL: https://new.vestnik-surgery.com/index.php/2415-7805/article/view/6709
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Abstract
Relevance. The current situation in world medicine is due to the struggle
with a new coronavirus infection and its complications. Models of the pathogenetic effect of coronavirus 2 acute respiratory syndrome (SARS-CoV-2) in the new coronavirus infection 2019 (COVID-19) on the brain indicate the possibility of both direct and indirect damage. Stroke or acute cerebrovascular accidents are the most common cause of disability and death worldwide. Stroke is also one of the most common complications of a new coronavirus infection from
nervous system.
Purpose. To study the features of the course of ischemic stroke and the features of rehabilitation in the early recovery period in patients with COVID-19 disease
Methods. The analysis of a patient with stroke by ischemic type, developed against the background of bacterial
viral pneumonia of mild severity in a patient with COVID-19.
Results. Treatment, methods and
the results of early rehabilitation, as well as the prognosis of the disease.
Conclusion. The considered case of a complicated course
a new coronavirus infection with the development of ischemic stroke,
proved the effectiveness of the successive management of the patient in
specialized centers for the treatment of COVID-19 and acute cerebrovascular accidents and high economic efficiency, the social significance of intensive multi-vector treatment and rehabilitation from the very
onset of the disease
Full Text
Relevance
The current situation in world medicine is due to the struggle
with a new coronavirus infection and its complications. Models of the pathogenetic effect of coronavirus 2 acute respiratory syndrome (SARS-CoV-2) in the new coronavirus infection 2019 (COVID-19) on the brain indicate the possibility of both direct and indirect damage. Stroke or acute cerebrovascular accidents are the most common cause of disability and death worldwide. Stroke is also one of the most frequent complications of a new coronavirus infection from the nervous system. One of the vivid illustrations of the work of neurologists in our Republic of Belarus is a clinical case of patient O. being treated in October – November 2020. The novelty in the work was added by the presence of ONMK against the background of the just transferred
coronavirus infection.
Clinical case
Medical history: patient O., born in 1969, was treated from 17 to 26.10.2020 in a specialized department of one of the hospitals in the city of Voronezh for patients with a new coronavirus infection (that is, in the center of category "B") with a diagnosis : “Coronavirus infection caused by the COVID-19 virus. Community-acquired pneumonia of viral and bacterial etiology, mild course. DN 0 ", from 10/26/2020 to 11/12/2020, in the same institution, inpatient treatment was carried out for CMB, diagnosis:“ CMB, ischemic stroke in the basin of the left MCA from 10/26/2020, an unspecified pathogenetic variant with the formation zones of ischemia in the left and right hemispheres of the cerebellum and in the region of the basal nuclei on the left, with spastic tetraparesis with a predominance on the left, dysarthria syndrome, severe trunk ataxia, cognitive impairment. Cystic changes in the left hemisphere of the brain. Neurogenic bladder.
Dyscirculatory encephalopathy 2, decompensation stage, cephalgic
syndrome, vestibuloatactic disorders. Hypertension 3, risk
MTR 4. ABS. CHF stage 1 ".
Transferred to the department of ONMK BUZ VO "Kalacheevskaya RB" for early
rehabilitation on 12/11/2020, where he was until 16/11/2020 (short term
hospitalization was associated with aggravated problems with
urination), was admitted to our Republic of Belarus in the acute period of stroke (up to 21 days
from the moment of development).
The situation with the function of the patient's respiratory system was assessed
as stable, the diagnosis of the therapist and infectious disease specialist upon admission:
"Coronavirus infection caused by the COVID-19 virus, PCR at
a study carried out three times on October 29, October 31, and November 5, 2020, negative.
Community-acquired pneumonia of viral and bacterial etiology, mild course,
DN 0 ". According to CT of the lungs, there is a significant positive dynamics in
compared with the onset of the disease: 10/16/2020 - signs of bilateral
polysegmental pneumonia, CT 2 lesion volume, COVID-19 probability
high. Conclusion CT from 05.11.2020: signs of bilateral viral
pneumonia, CT 1 (positive dynamics). According to reports,
the patient's presence in the general department did not pose a threat to
others.
Complaints noted upon admission to the Kalacheyevskaya RB: head
pain, dizziness, poor memory, weakness in the limbs, more in the left,
inability to maintain the vertical position of the body, violation
speech, fear, urinary disorders.
Neurological status: clear consciousness, in place, time, own
the personality is oriented correctly; from the side of the cranial nerves - without
features; strength in the right limbs - 4 points, in the left limbs - 1
point, the tone in them is increased according to the spastic type, deep reflexes
lively on both sides; does not perform coordination tests, withholding
sitting position is impossible due to ataxia; positive pathological
foot marks on both sides, delay-type pelvic dysfunction
urine, urination through the catheter, no sensory disturbances were received,
there was severe dysarthria; emotionally extremely labile, extremely
worried about his health, expresses obsessive fears, fears;
dyssomnia, depressive mood are noted [3].
Present symptoms: motor, atactic, cerebellar,
cognitive, emotional-volitional disorders, post-stroke disorders
function of the bladder.
Upon admission, testing was carried out according to standard
methods: NIHSS - 19, Rehabilitation routing scale - 5, index
Rivermead mobility - 0.
Rehabilitation goals: to increase the degree of self-care, to reduce
the degree of focal neurological, emotional, cognitive impairment,
normalize the passage of urine [2, 4, 5].
Period of stroke at the time of admission to the Republic of Belarus (10 days from occurrence)
treated as acute (up to 21 days).
Data from the most important surveys:
X-ray CT of the brain from 10/12/2020: ischemic stroke in
the left hemisphere of the cerebellum. Forming cystic changes in the left
hemisphere of the brain.
Ultrasound of the bladder from 11/16/2020: Urinary retention.
Examination by a urologist from 11/16/2020: Neurogenic bladder.
Chronic urinary retention. Urethritis.
During the previous inpatient treatment in the department,
specializing in the admission of patients with a new coronavirus infection,
correction of bladder dysfunction was performed - conservative
therapy did not give the desired effect, but the patient refused in writing
the epicystostomy prescribed by the urologist. In the future, the situation with
urinary tract exacerbated, and on November 16, 2020, the patient was
hospitalized in the urology department, where an urgent
epicystostomy after obtaining the patient's consent to the operation. After
stabilizing the situation was again hospitalized in the department for treatment
ONMK 11/23/2020
Positive dynamics in neurological status during translation
is absent, on the part of the mental status, the emotional
lability, concern about one's well-being, dyssomnia, depressive
mood,periodically with mild visual hallucinations.
Surveys carried out: UZDS BCA from 11/25/2020: effect
stagnation (thickening) of blood in the IJV on the left, non-rectilinear course of the PA on the left in 2
segment due to vertebrogenic influence.
General urinalysis: partial sanitation achieved:
11/23/2020: density 1012, protein 0.31 g / l, leukocytes 23-25-38 in p.z.,
erythrocytes 4–5–6 in the PC, mucus +.
12/04/2020: density 1013, protein 0.1 g / l, leukocytes 19-17-15 in p.z.,
erythrocytes 1–2–3 per p.z., mucus 0.
Received the following treatment: neurocytoprotectors (Cereton 4 ml (1000
- mg) No. 10, Mexidol 5% 5 ml No. 10, Cytoflavin 10 ml intravenously drip),
on the recommendation of a urologist - antibiotic therapy: amikacin 1 g 2 times a day
intravenously for 10 days. Due to the long immobile state for
prevention of secondary thromboembolic complications received
anticoagulants (heparin 20 thousand units per day subcutaneously for 14 days), treatment according to
recommendations of a cardiologist (antihypertensive therapy intravenously drip
magnesium sulfate 25% 10 ml No. 5, oral lisinopril 5 mg per day 13
days), lipid-lowering therapy (simvastatin 20 mg at night), sedation (in
the form of antidepressants and antipsychotics Elzepam 1 ml intramuscularly No. 5,
haloperidol 1 ml intramuscularly No. 5, amitriptyline 2.5% 2 ml No. 3
intramuscularly), regular bowel movements were controlled
non-drug methods [4-7]. Classes were held with specialists
multidisciplinary team [4]: physiotherapy (magnetotherapy along
spine No. 7), massage of the chest according to the gentle method No. 10; Exercise therapy:
breathing exercises, posture treatment, passive verticalization,
early activation; psychological counseling of the patient and members
families, rational psychotherapy, occupational therapy for the purpose of recovery
self-care skills, speech therapy counseling and treatment
dysarthria.
Final Clinical DS: "CVD: Recovery Period
CMC - ischemic stroke in the left MCA from 10/26/2020, unspecified
pathogenetic variant with the formation of ischemic zones in the left hemisphere
cerebellum and in the region of the thalamus on the left, with a syndrome of dysarthria, expressed
trunk ataxia, pronounced spastic tetraparesis with
predominance on the left, cognitive impairment, asthenosubdepressive
syndrome. Cystic changes in the left hemisphere of the brain.
Neurogenic bladder. Chronic urinary retention.
Urethritis. Epicystostomy from 17.11.2020, Dyscirculatory encephalopathy 2,
decompensation stage, cephalgic syndrome, vestibuloatactic
violations. Essential hypertension 3, risk of CVC 4. ABS. CHF 1 tbsp.
Coronavirus infection caused by COVID-19 virus (start of treatment for
10/17/2020). Community-acquired pneumonia of viral and bacterial etiology,
easy course, period of convalescence. DN 0 ".
Treatment results:
1) the passage of urine through the epicystostomy is normalized, sanitation has occurred
urine, visually light urine along the catheter, normalization is achieved and
general urine analysis, and biochemical blood test; persists
violation of pelvic functions by the type of urinary retention;
2) normalization of mental status in the form of disappearance of obsessive
fears and fears, better sleep, the emergence of cooperation with staff
medical and rehabilitation profile in achieving the set goals,
disappearance of negativism;
3) increasing the level of mobility, the degree of self-service against the background
improvement of indicators of neurological status and decrease in severity
paresis, ataxia, reduction of dysarthric manifestations; with certainty
sits in bed, takes food on his own, can shave himself, wash
head, partially treat the body with wet wipes, went into
upright position with a walker, began to take steps about
supports with outside control [5].
The goals of rehabilitation have been achieved and in quantitative terms in the form
decrease in standard NIHSS scores from 19 to 16 points, changes
points of the Scale of rehabilitation routing from 5 to 4, index
Rivermead mobility from 0 to 7 [4].
The prognosis for recovery and restoration of the functions of the nervous,
respiratory, cardiovascular system favorable, by function
urinary system, the prognosis is doubtful. Likely conservation
residual phenomena of paresis and ataxia with a further prospect of reaching
disability, but partial self-care.
Recommendations for secondary prevention of stroke are given,
corrected hypotensive (perindopril 10 mg 1-2 times a day,
indapamide 2.5 mg per day, amlodipine 5 mg once a day with high numbers
BP), hypolipidemic (atoris 20 mg at night under the control of
cholesterol, lipoproteins, atherogenic index after 2 months),
anticoagulant (warfarin 2.5 mg once a day after dinner under control
INR after 2 days) therapy [5]; maintenance therapy prescribed
neuroprotective agents (Mexidol 125 mg 3 times 1 month, Cereton 1 capsule 3 times a
day 1 month, cytoflavin 2 tablets 2 times 1 month), activities for
prevention of stress ulcers (proton pump inhibitor omeprazole 20 mg 2
once a day for 1 month), registration with a dispensary to a neurologist and urologist,
therapist, infectious disease specialist at the place of residence [4, 6, 7].
Sent to the 2nd stage of rehabilitation in the rehabilitation department for
of patients with stroke from 04.12.2020 The patient and relatives were informed about
terms of referral to the ITU in the presence of persistent neurological defects
at the end of the rehabilitation period [6, 7]. The result of the 2nd stage of rehabilitation:
recovered independent walking, controls the pelvic functions,
the epicystomy was closed.
Conclusion
This article discusses the case of a complicated course
a new coronavirus infection with the development of ischemic stroke,
the effectiveness of the successive management of the patient in
specialized centers for the treatment of COVID-19 and stroke, inpatient
rehabilitation taking into account individual characteristics in the form of problems
urological profile and long-term correction of hypercoagulation. For 3 months
treatment, a lasting result was achieved in the form of restoration of independent
walking and disappearance of pelvic disorders. As a consequence, instead of
the need for long-term outside care for a patient with rough
dysfunction, the prospect of moderate a neurological defect, that is, the patient will be identified in 3, and not in 1 group disability. Intensive multi-directional treatment and rehabilitation from the very beginning
onset of the disease are highly cost-effective and
social significance.
About the authors
Mark Dzhalatovich Bedirov
Author for correspondence.
Email: bedirovmark@inbox.ru
ORCID iD: 0000-0003-1818-0719
Russian Federation
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