【摘要】：[背景] 顱腦損傷(traumatic brain injury, TBI)是外傷疾病中的常見病,嚴重危害人類健康和威脅患者生命。隨著我國經濟發(fā)展,交通、建筑事業(yè)的日益發(fā)展,隨之帶來的意外事故發(fā)生增加,以及運動損傷和自然災害等致傷因素的存在,使得顱腦損傷發(fā)病率增高。目前我國每年顱腦損傷的發(fā)生率為100/10萬人,已經接近發(fā)達國家。在其他許多嚴重危害人類健康的疾病,如傳染病等逐漸得到有效治療和控制的今天,顱腦損傷的發(fā)生率以及病死率卻仍呈現(xiàn)居高不下,其危害愈顯突出。只要有人類活動存在,顱腦損傷就不可能徹底消失,因此減少顱腦損傷發(fā)生及給予顱腦損傷患者最大限度的控制和救治,對于維護人們身體健康,有重要現(xiàn)實意義。其中重型顱腦損傷(severe traumatic brain injury, STBI)危害極大,其致殘、致死率高,是目前神經外科救治的重點和難點。重型顱腦損傷患者病情危重,昏迷時間長,嚴重危害患者健康。對急性嚴重顱腦創(chuàng)傷救治技術的進步,使得嚴重顱腦創(chuàng)傷患者的病死率急劇下降。但隨之而來的問題是部分嚴重顱腦創(chuàng)傷患者經救治后仍處于長期昏迷或植物狀態(tài),給患者家庭帶來極大的心理以及經濟負擔,而且維持昏迷患者的生命也需要耗費大量的社會資源。因此,對這部分患者的預后進行評估或預測,對于臨床治療方案的制定有重要意義,并且,在我國目前衛(wèi)生資源有限且分布不均的情況下,早期預測這部分患者的預后有很高的現(xiàn)實意義。 目前,對重型顱腦損傷昏迷患者的預后評估在國內外都進行了大量的研究,國內外研究主要涵蓋了神經行為學與腦干反射、影像學表現(xiàn)、生理生化改變以及神經電生理學檢測等多個方面,取得顯著成果。目前,神經電生理檢測已成為評價昏迷患者預后的主要手段之一,臨床上廣泛應用的神經電生理檢測有腦電圖、腦干聽覺誘發(fā)電位(brainstem auditory evoked potential, BAEP)和體感誘發(fā)電位(somatosensory evoked potential, SEP)。腦電圖檢測廣泛應用于臨床,在病情、預后評估等方面發(fā)揮了良好的作用,為臨床診療提供可靠的客觀依據(jù)。腦電圖反映的是大腦皮質的生物電活動,可揭示CT、MRI、血管造影等難以顯示的異常狀況,Synek于1988年首先將腦電圖反應性引入分級標準,并得到Gutling等[1]研究證實,即腦電圖反應性與預后關系顯著,反應性的存在依賴于腦干網狀結構和丘腦皮質通路的完整。腦電圖操作簡單易行,它對被檢查者沒有任何創(chuàng)傷,可重復動態(tài)觀測,因此是臨床上不可缺少的檢測與評價技術。影像學檢查(如：頭顱CT、MRI)是目前顱腦損傷后臨床上最常用的輔助檢查,能從形態(tài)、結構上對顱腦損傷程度進行直接評估,為預后作出判斷。因此,鑒于目前腦電圖檢查及頭顱CT檢查的普及,并且也可以為臨床醫(yī)師判斷病情、制訂治療方案及評估預后提供了客觀的參考信息,本研究采用腦電圖反應性和頭顱CT檢查對重型顱腦損傷昏迷患者的預后進行評估,進一步探討其對重型顱腦損傷昏迷患者預后判斷的意義,便于臨床參考。 [目的] 本研究通過對重型顱腦損傷昏迷患者的腦電圖反應性以及頭顱CT中腦形態(tài)等臨床資料進行研究分析,旨在探討腦電圖反應性、頭顱CT中腦形態(tài)與重型顱腦損傷昏迷患者預后的關系,為臨床應用提供依據(jù)。 [研究對象和方法] 1.一般資料 1.1臨床資料：收集2011年4月至2012年10月我院神經外科收治的重型顱腦損傷昏迷患者116例,其中男78例,女38例；年齡5-74(39.55±14.01)歲；所有患者均于傷后24h內入院,入院時格拉斯哥昏迷量表(GCS)評分≤8分,其中車禍傷72例,硬物打擊傷21例,高處墜落傷16例,跌傷、摔傷7例；116例患者中有69例接受手術治療。在排除低溫及藥物的影響情況下對所有病人行EEG監(jiān)測(手術病人于傷后48-72小時內監(jiān)測,監(jiān)測時間不低于30分鐘)。116例患者入院時一側瞳孔散大者34例,雙側瞳孔散大者23例。住院時間平均為67.30±5.37天(3-169天)。 1.2病例納入標準：①均于傷后24小時內入院的患者；②患者入院時均為昏迷狀態(tài),格拉斯哥昏迷分級(GCS)評分≤8分；③患者入院時均行頭顱CT檢查；④患者入院時顱腦損傷分型為重型者；⑤年齡為5-75歲的患者。 1.3病例排除標準：①既往有癲癇病史患者；②既往有顱腦外傷史、腦血管意外史、顱內占位病史以及顱內感染病史者；③既往有精神病史或吸毒、長期嗜酒史者；④既往有嚴重心、肺、肝、腎等重要臟器功能不全病史者；⑤受鎮(zhèn)靜藥物影響患者；⑥隨訪期內放棄治療者。 2.研究方法 2.1準確測量昏迷患者入院時頭顱CT中腦水平前后徑與橫徑的值,并計算其比值,并于入院早期(≤3d),在排除低溫及藥物的影響情況下對所有病人行EEG監(jiān)測(手術病人于傷后48-72小時內監(jiān)測,監(jiān)測時間不低于30分鐘,非手術者于傷后72h內監(jiān)測,監(jiān)測時間不低于30min),EEG記錄中給予疼痛(按壓鼻中隔)和聲音刺激(耳邊呼喚),用視覺判定EEG反應性。 2.2將患者入院時測量的中腦水平前后徑與橫徑的比值分為兩組：(1)0.9-1.1,(2)1.1或0.9；隨訪結束時,患者的預后按照格拉斯哥預后分級(Glasgow outcome scale GOS)評分分為兩組：預后良好組(GOS評分4-5分,即預后良好和輕度殘疾)；預后不良組(GOS評分1-3分,即重度殘疾、植物生存狀態(tài)和死亡)。通過統(tǒng)計分析,探討重型顱腦損傷昏迷患者入院時頭顱CT中腦水平前后徑與橫徑的比值與預后的關系。 2.3所有患者均于入院早期(≤3d),在排除低溫及藥物的影響情況下對所有病人行EEG監(jiān)測(手術病人于傷后48-72小時內監(jiān)測,監(jiān)測時間不低于30分鐘),EEG記錄中給予疼痛(按壓鼻中隔)和聲音刺激(耳邊呼喚),用視覺判定EEG反應性參照Gutling等[1]腦波的變化,給予刺激后,慢波產生及節(jié)律波的變平視為有反應,兩側EEG記錄沒有變化或可疑變化則視為無反應。通過統(tǒng)計分析,探討重型顱腦損傷昏迷患者傷后早期腦電圖反應性與預后的關系。 2.4將腦電圖反應性結果與頭顱CT中腦前后徑與橫徑比值兩者聯(lián)合,分為四組：第一組：腦電圖有反應且中腦前后徑與橫徑比值為0.9-1.1；第二組：腦電圖無反應且中腦前后徑與橫徑比值1.1或0.9；第三組：腦電圖有反應且中腦前后徑與橫徑比值1.1或0.9；第四組：腦電圖無反應且中腦前后徑與橫徑比值為0.9-1.1。研究腦電圖反應性與頭顱CT檢查聯(lián)合應用在重型顱腦損傷昏迷患者預后評估中的作用。 2.5分別計算腦電圖反應性、頭顱CT中腦前后徑與橫徑的比值以及兩者聯(lián)合對預后評估的價值,用敏感性、特異性、準確率、錯誤率表示。敏感度(sensitivity positive, SE)又稱真陽性率,是實際患病且被試驗診斷為患者的概率；特異度(specificity positive, SP)又稱真陰性率,是實際未患病而被試驗診斷為非患者的概率。 EEG反應性、中腦前后徑比值對預后評估價值的計算方法：真陰性(true negative, TN):指標較良好且預后良好的患者；假陰性(false positive, FN):指標較良好且預后不良的患者；真陽性(true positive, TP):指標不良且預后不良的患者；假陽性(false positive, FP):指標不良且預后良好的患者；敏感性(sensitivity, SE)=[TP/(TP+FN)] x100%;特異性(specificity, SP)=[TN/(TN+FP)]×100%。準確率=TN+TP/116。錯誤率=FP/116。 3.統(tǒng)計學方法 所有數(shù)據(jù)采用SPSS13.0統(tǒng)計學軟件進行分析,兩個獨立樣本率比較采用x2檢驗。P0.05為差異有統(tǒng)計學意義。 [結果] 1.兩組頭顱CT中腦水平前后徑與橫徑的比值對昏迷患者的預后良好率相比較,經四格表資料的x2驗檢,差異有統(tǒng)計學意義(x2=25.119,P=0.000)。 2.116例昏迷患者腦電圖有無反應性的預后良好率相比較,經四格表資料的x2檢驗,差異有統(tǒng)計學意義(x2=54.296,P=0.000)。 3.腦電圖反應性與頭顱CT中腦前后徑與橫徑的比值聯(lián)合分為四組,經R×C表資料的x2檢驗,四組患者的預后良好率比較,差異有統(tǒng)計學意義(x2=58.507,P=0.000)。 4.EEG反應性檢測的敏感性83.67%、特異性85.07%、準確率84.48%、錯誤率8.62%,頭顱CT檢查的敏感性75.51%、特異性71.64%、準確率73.28%、錯誤率16.37%；EEG反應性聯(lián)合頭顱CT檢測的敏感性91.42%、特異性89.58%、準確率90.36%、錯誤率5.88%。 [結論] 1.腦電圖反應性及中腦形態(tài)與重型顱腦損傷昏迷患者的預后有相關性,可應用其對患者的預后進行有效評估。 2.腦電圖反應性與頭顱CT中腦形態(tài)聯(lián)合應用可以有效地對重型顱腦損傷昏迷患者的預后進行評估。
[Abstract]:[background]
Traumatic brain injury (TBI) is a common disease in traumatic diseases. It seriously endangers human health and threatens the life of the patients. With the development of the economy, the increasing development of traffic and construction, the increase of accidents, as well as the existence of injuries and natural disasters, so as to cause brain injury. The rate of disease is increasing. The incidence of craniocerebral injury in China is now 100/10 10000 people, which is close to the developed countries. In many other diseases, such as infectious diseases, such as infectious diseases, the incidence of craniocerebral injury and the mortality rate are still high. The brain injury can not disappear completely in human activities. Therefore, it is of great practical significance to reduce the occurrence of craniocerebral injury and the maximum control and treatment of the patients with craniocerebral injury. The severe craniocerebral injury (severe traumatic brain injury, STBI) is very harmful, and it is disabled and has a high mortality rate. At present, the key and difficult point of treatment in Department of neurosurgery. Severe craniocerebral injury patients are critically ill, long coma time, seriously endangering the patient's health. The progress of acute severe craniocerebral trauma treatment technology makes the death rate of severe craniocerebral trauma patients decrease sharply. Being in a long-term coma or plant state brings great psychological and economic burden to the family, and it also takes a lot of social resources to maintain the life of the comatose. Therefore, the assessment or prediction of the prognosis of this part of the patient is of great importance to the establishment of a clinical treatment scheme, and the current health resources in our country. Limited and uneven distribution, early prediction of the prognosis of this part of patients has high practical significance.
At present, a large number of studies have been conducted at home and abroad for the prognosis assessment of severe craniocerebral injury comatose patients. Domestic and foreign research mainly covers many aspects, such as neurobehavioral and brainstem reflex, imaging performance, physiological and biochemical changes and neurophysiological tests, and has made significant achievements. At present, the neurophysiological detection has become an evaluation. One of the main methods for the prognosis of coma patients, the clinically widely used neuroelectrophysiological tests are electroencephalogram, brainstem auditory evoked potential (BAEP) and somatosensory evoked potential (somatosensory evoked potential, SEP). Electroencephalogram (somatosensory evoked potential, SEP) is widely used in clinical diagnosis and prognosis evaluation. It provides a reliable objective basis for clinical diagnosis and treatment. Electroencephalogram (EEG) reflects the bioelectrical activity of the cerebral cortex. It can reveal the abnormal conditions such as CT, MRI, angiography and so on. In 1988, Synek first introduced the electroencephalogram responsiveness to the classification standard, and was confirmed by [1] studies such as Gutling, that is, the electroencephalogram reactivity and prognosis. The relationship is significant. The existence of reactivity depends on the brain stem reticular formation and the integrity of the thalamocortical pathway. Electroencephalography is simple and easy to operate. It has no trauma to the examiners and can be repeated dynamic observation. Therefore, it is an indispensable clinical detection and evaluation technique. Imaging examination (such as head CT, MRI) is the clinical case of brain injury. The most commonly used auxiliary examinations can be used to assess the degree of craniocerebral injury in form and structure, and to judge the prognosis. Therefore, in view of the current electroencephalogram examination and the popularization of the head CT examination, it can also provide an objective reference for the clinician to judge the condition, formulate the treatment plan and evaluate the preview, and use the electroencephalogram (EEG) in this study. The prognosis of patients with severe craniocerebral injury coma was evaluated by graph reactivity and craniocerebral CT examination, and the significance of the prognosis of patients with severe craniocerebral injury coma was further discussed, which was convenient for clinical reference.
[Objective]
In this study, the clinical data of electroencephalogram (EEG) responsiveness and head CT in the head of severe craniocerebral injury patients were studied and analyzed. The purpose of this study was to explore the relationship between the electroencephalogram reactivity, the brain morphology of head CT and the prognosis of the coma patients with severe craniocerebral injury, and to provide the basis for clinical application.
[object and method of research]
1. general information
1.1 clinical data: 116 cases of severe craniocerebral injury coma in our department of neurosurgery from April 2011 to October 2012 were collected, of which 78 cases were male and 38 women, aged 5-74 (39.55 + 14.01) years old. All the patients were hospitalized within 24h after injury, and the Glasgow Coma Scale (GCS) score was less than 8, including 72 in car accident and 21 hard hit injury. There were 16 cases of high fall and 7 cases of fall and fall, and 69 cases of 116 patients received surgical treatment. EEG monitoring was performed on all patients under the condition of removing the low temperature and the effect of Medicine (the operation patients were monitored within 48-72 hours after the injury, and the monitoring time was not less than 30 minutes). 34 cases of the dilated pupil at the side of the hospital and the dilatation of the bilateral pupil at the admission of the patients in the hospital. 23 cases. The average length of stay was 67.30 + 5.37 days (3-169 days).
1.2 cases were included in the standard: (1) all the patients were hospitalized within 24 hours after injury; (2) the patients were all comatose at admission and the Glasgow Coma Scale (GCS) score was less than 8; (3) the patients were admitted to the hospital with head CT examination; (4) the patients were divided into severe type of craniocerebral injury when hospitalized; 5 years old were 5-75 years old.
1.3 case exclusion criteria: (1) patients with previous history of epilepsy; (2) history of craniocerebral trauma, cerebrovascular accident, intracranial space occupying and history of intracranial infection; (3) those who had a history of mental illness or drug addiction and a long history of alcohol addiction; (4) patients with serious heart, lung, liver, kidney and other important organ dysfunction in the past; 5 The patients were affected and the patients were abandoned during the follow-up period.
2. research methods
2.1 accurately measured the value of the anterior and posterior diameter and transverse diameter of the head CT midbrain at the time of admission to the coma patients, and calculated the ratio, and at the early stage of admission (< < 3D), all patients were monitored by EEG under the condition of removing the low temperature and the effect of drugs. The operation patients were monitored within 48-72 hours after the injury, and the monitoring time was not less than 30 minutes. The non operative persons were in the 72h supervision after the injury. The monitoring time was no less than 30 minutes. Pain (pressing the nasal septum) and sound stimulation (ear call) were given to EEG records. EEG responsiveness was judged by visual acuity.
2.2 the ratio of the median and transverse diameters measured by the patient was divided into two groups: (1) 0.9-1.1, (2) 1.1 or 0.9; at the end of the follow-up, the prognosis of the patients was divided into two groups according to the Glasgow prognostic rating (Glasgow outcome scale GOS): a good prognosis group (GOS score 4-5, good prognosis and mild disability); poor prognosis; poor prognosis; poor prognosis. Group (GOS score 1-3, severe disability, plant survival state and death). Through statistical analysis, the relationship between the ratio of the anterior and posterior diameter of the head of head CT in the head of the head of the head with severe craniocerebral injury to the prognosis of the brain was discussed.
2.3 all patients were at the early stage of admission (< 3D). EEG monitoring was performed on all patients under the influence of hypothermia and drugs. The patients were monitored within 48-72 hours after the injury, and the monitoring time was not less than 30 minutes. The EEG records were given to pain (press nasal septum) and sound stimulation (the ear call), and EEG reactivity was used to judge the Gutling and so on. The changes in the 1] brain wave, after the stimulation, the slow wave generation and the variable vision of the rhythmic waves were reacted, and the two sides of the EEG records were not changed or suspicious. The relationship between the early EEG reactivity and the prognosis of the patients with severe head injury coma after injury was investigated by statistical analysis.
2.4 combined the results of electroencephalogram reactivity with the ratio of anterior and posterior diameter and transverse diameter of head CT into four groups: the first group: the electroencephalogram was reacted and the ratio of the middle and transverse diameter of the middle brain to the lateral diameter was 0.9-1.1; the second groups: the electroencephalogram was not reacted and the ratio of the anterior and posterior diameter to the transverse diameter was 1.1 or 0.9; the third groups: electroencephalogram had reaction and the anterior and posterior diameter of the middle brain. The ratio of the transverse diameter to 1.1 or 0.9; the fourth groups: the ratio of the electroencephalogram without reaction and the ratio of the diameter to the transverse diameter of the middle brain was 0.9-1.1. to study the role of the combined application of electroencephalogram reactivity and cranial CT in the prognosis evaluation of patients with severe head injury coma.
2.5 to calculate the ratio of electroencephalogram reactivity, the ratio of the anterior and posterior diameter of the brain to the transverse diameter in the head CT, and the value of the combination for the evaluation of the prognosis, with sensitivity, specificity, accuracy and error rate. The sensitivity (sensitivity positive, SE), also known as the true positive rate, is the probability of the actual illness and the test was diagnosed as the patient; the specificity (specificity PO) Sitive (SP), also known as the true negative rate, is the probability of being diagnosed as a non patient without actual illness.
The value of EEG reactivity and the ratio of midbrain diameter to prognosis assessment: true negative (true negative, TN): Patients with better indicators and better prognosis; false negative (false positive, FN): Patients with better indicators and poor prognosis; true positive (true positive, TP): Patients with poor indicators and poor prognosis; false positive (false) Positive, FP): Patients with poor indicators and good prognosis; sensitivity (sensitivity, SE) =[TP/ (TP+FN) x100%; specificity (specificity, SP) =[TN/ (TN+FP)] * 100%. accuracy error rate
3. statistical method
All data were analyzed by SPSS13.0 statistical software. The two independent sample rates were compared by x2 test. The difference was statistically significant in P 0.05.
[results]
1. the ratio of the anterior and posterior diameter to the transverse diameter of the head CT in the two groups was compared to the good prognosis of the coma patients, and the difference was statistically significant (x2=25.119, P=0.000) through the examination of the four lattice data.
2.116 comatose patients had better prognosis than non-comatose patients. The difference was statistically significant (x2 = 54.296, P = 0.000) by x2 test of four-grid data.
The ratio of 3. electroencephalogram reactivity with the ratio of anterior and posterior diameter of head CT into four groups was divided into four groups. The prognosis of the four groups was statistically significant (x2=58.507, P=0.000) by the x2 test of the four groups.
The sensitivity of 4.EEG was 83.67%, the specificity was 85.07%, the accuracy was 84.48%, the error rate was 8.62%, the sensitivity of the head CT examination was 75.51%, the specificity was 71.64%, the accuracy rate was 73.28%, the error rate was 16.37%; the sensitivity of the EEG reactivity combined with the head CT was 91.42%, the specificity 89.58%, the accuracy rate 90.36%, and the error rate 5.88%..
[Conclusion]
1. Electroencephalogram reactivity and midbrain morphology are correlated with the prognosis of comatose patients with severe craniocerebral injury.
2. The combination of EEG reactivity and brain morphology in cranial CT can effectively evaluate the prognosis of coma patients with severe craniocerebral injury.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2013
【分類號】：R651.15

【參考文獻】

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1 但煒,唐文淵,劉福英;腦電圖反應性對急性重型腦傷患者預后的評估研究[J];創(chuàng)傷外科雜志;2004年06期

2 肖棉棉;陳彩琴;陳漢民;;顱腦外傷911例的腦電圖臨床分析[J];臨床軍醫(yī)雜志;2012年01期

3 黃偉年;鄧章基;張海江;徐碧文;郎洪剛;吳欣洪;羅富華;閆淑麗;;國人環(huán)池的CT觀測及其臨床意義研究[J];臨床神經外科雜志;2010年02期

4 馮永仁;昏迷病人的腦電圖表現(xiàn)及與預后的關系[J];臨床腦電學雜志;2000年02期

5 王翠欣,高曉峰,耿梅,王亞娟,陳穎,魏巍;動態(tài)腦電圖加刺激對昏迷病人預后的臨床觀察[J];臨床神經電生理學雜志;2004年03期

6 楊伯捷,趙大力,李盛昌,徐啟武;多種誘發(fā)電位評估急性昏迷病人的預后[J];復旦學報(醫(yī)學科學版);2001年05期

7 龍連圣,王偉明,江基堯;CT環(huán)池影像對急性顱腦損傷患者預后的預測[J];中華神經外科疾病研究雜志;2003年01期

8 蒲娟;;昏迷患者腦電圖表現(xiàn)及其臨床應用價值[J];實用心腦肺血管病雜志;2012年05期

9 徐偉偉;王向宇;;顱腦損傷后長期昏迷患者預后預測方法的研究進展[J];中國臨床神經外科雜志;2008年05期

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