脑电图反应性联合中脑形态对重型颅脑损伤昏迷患者预后评估的临床研究

发布时间：2018-08-01 09:13

【摘要】：[背景] 颅脑损伤(traumatic brain injury, TBI)是外伤疾病中的常见病,严重危害人类健康和威胁患者生命。随着我国经济发展,交通、建筑事业的日益发展,随之带来的意外事故发生增加,以及运动损伤和自然灾害等致伤因素的存在,使得颅脑损伤发病率增高。目前我国每年颅脑损伤的发生率为100/10万人,已经接近发达国家。在其他许多严重危害人类健康的疾病,如传染病等逐渐得到有效治疗和控制的今天,颅脑损伤的发生率以及病死率却仍呈现居高不下,其危害愈显突出。只要有人类活动存在,颅脑损伤就不可能彻底消失,因此减少颅脑损伤发生及给予颅脑损伤患者最大限度的控制和救治,对于维护人们身体健康,有重要现实意义。其中重型颅脑损伤(severe traumatic brain injury, STBI)危害极大,其致残、致死率高,是目前神经外科救治的重点和难点。重型颅脑损伤患者病情危重,昏迷时间长,严重危害患者健康。对急性严重颅脑创伤救治技术的进步,使得严重颅脑创伤患者的病死率急剧下降。但随之而来的问题是部分严重颅脑创伤患者经救治后仍处于长期昏迷或植物状态,给患者家庭带来极大的心理以及经济负担,而且维持昏迷患者的生命也需要耗费大量的社会资源。因此,对这部分患者的预后进行评估或预测,对于临床治疗方案的制定有重要意义,并且,在我国目前卫生资源有限且分布不均的情况下,早期预测这部分患者的预后有很高的现实意义。目前,对重型颅脑损伤昏迷患者的预后评估在国内外都进行了大量的研究,国内外研究主要涵盖了神经行为学与脑干反射、影像学表现、生理生化改变以及神经电生理学检测等多个方面,取得显著成果。目前,神经电生理检测已成为评价昏迷患者预后的主要手段之一,临床上广泛应用的神经电生理检测有脑电图、脑干听觉诱发电位(brainstem auditory evoked potential, BAEP)和体感诱发电位(somatosensory evoked potential, SEP)。脑电图检测广泛应用于临床,在病情、预后评估等方面发挥了良好的作用,为临床诊疗提供可靠的客观依据。脑电图反映的是大脑皮质的生物电活动,可揭示CT、MRI、血管造影等难以显示的异常状况,Synek于1988年首先将脑电图反应性引入分级标准,并得到Gutling等[1]研究证实,即脑电图反应性与预后关系显著,反应性的存在依赖于脑干网状结构和丘脑皮质通路的完整。脑电图操作简单易行,它对被检查者没有任何创伤,可重复动态观测,因此是临床上不可缺少的检测与评价技术。影像学检查(如：头颅CT、MRI)是目前颅脑损伤后临床上最常用的辅助检查,能从形态、结构上对颅脑损伤程度进行直接评估,为预后作出判断。因此,鉴于目前脑电图检查及头颅CT检查的普及,并且也可以为临床医师判断病情、制订治疗方案及评估预后提供了客观的参考信息,本研究采用脑电图反应性和头颅CT检查对重型颅脑损伤昏迷患者的预后进行评估,进一步探讨其对重型颅脑损伤昏迷患者预后判断的意义,便于临床参考。 [目的] 本研究通过对重型颅脑损伤昏迷患者的脑电图反应性以及头颅CT中脑形态等临床资料进行研究分析,旨在探讨脑电图反应性、头颅CT中脑形态与重型颅脑损伤昏迷患者预后的关系,为临床应用提供依据。 [研究对象和方法] 1.一般资料 1.1临床资料：收集2011年4月至2012年10月我院神经外科收治的重型颅脑损伤昏迷患者116例,其中男78例,女38例；年龄5-74(39.55±14.01)岁；所有患者均于伤后24h内入院,入院时格拉斯哥昏迷量表(GCS)评分≤8分,其中车祸伤72例,硬物打击伤21例,高处坠落伤16例,跌伤、摔伤7例；116例患者中有69例接受手术治疗。在排除低温及药物的影响情况下对所有病人行EEG监测(手术病人于伤后48-72小时内监测,监测时间不低于30分钟)。116例患者入院时一侧瞳孔散大者34例,双侧瞳孔散大者23例。住院时间平均为67.30±5.37天(3-169天)。 1.2病例纳入标准：①均于伤后24小时内入院的患者；②患者入院时均为昏迷状态,格拉斯哥昏迷分级(GCS)评分≤8分；③患者入院时均行头颅CT检查；④患者入院时颅脑损伤分型为重型者；⑤年龄为5-75岁的患者。 1.3病例排除标准：①既往有癫痫病史患者；②既往有颅脑外伤史、脑血管意外史、颅内占位病史以及颅内感染病史者；③既往有精神病史或吸毒、长期嗜酒史者；④既往有严重心、肺、肝、肾等重要脏器功能不全病史者；⑤受镇静药物影响患者；⑥随访期内放弃治疗者。 2.研究方法 2.1准确测量昏迷患者入院时头颅CT中脑水平前后径与横径的值,并计算其比值,并于入院早期(≤3d),在排除低温及药物的影响情况下对所有病人行EEG监测(手术病人于伤后48-72小时内监测,监测时间不低于30分钟,非手术者于伤后72h内监测,监测时间不低于30min),EEG记录中给予疼痛(按压鼻中隔)和声音刺激(耳边呼唤),用视觉判定EEG反应性。 2.2将患者入院时测量的中脑水平前后径与横径的比值分为两组：(1)0.9-1.1,(2)1.1或0.9；随访结束时,患者的预后按照格拉斯哥预后分级(Glasgow outcome scale GOS)评分分为两组：预后良好组(GOS评分4-5分,即预后良好和轻度残疾)；预后不良组(GOS评分1-3分,即重度残疾、植物生存状态和死亡)。通过统计分析,探讨重型颅脑损伤昏迷患者入院时头颅CT中脑水平前后径与横径的比值与预后的关系。 2.3所有患者均于入院早期(≤3d),在排除低温及药物的影响情况下对所有病人行EEG监测(手术病人于伤后48-72小时内监测,监测时间不低于30分钟),EEG记录中给予疼痛(按压鼻中隔)和声音刺激(耳边呼唤),用视觉判定EEG反应性参照Gutling等[1]脑波的变化,给予刺激后,慢波产生及节律波的变平视为有反应,两侧EEG记录没有变化或可疑变化则视为无反应。通过统计分析,探讨重型颅脑损伤昏迷患者伤后早期脑电图反应性与预后的关系。 2.4将脑电图反应性结果与头颅CT中脑前后径与横径比值两者联合,分为四组：第一组：脑电图有反应且中脑前后径与横径比值为0.9-1.1；第二组：脑电图无反应且中脑前后径与横径比值1.1或0.9；第三组：脑电图有反应且中脑前后径与横径比值1.1或0.9；第四组：脑电图无反应且中脑前后径与横径比值为0.9-1.1。研究脑电图反应性与头颅CT检查联合应用在重型颅脑损伤昏迷患者预后评估中的作用。 2.5分别计算脑电图反应性、头颅CT中脑前后径与横径的比值以及两者联合对预后评估的价值,用敏感性、特异性、准确率、错误率表示。敏感度(sensitivity positive, SE)又称真阳性率,是实际患病且被试验诊断为患者的概率；特异度(specificity positive, SP)又称真阴性率,是实际未患病而被试验诊断为非患者的概率。 EEG反应性、中脑前后径比值对预后评估价值的计算方法：真阴性(true negative, TN):指标较良好且预后良好的患者；假阴性(false positive, FN):指标较良好且预后不良的患者；真阳性(true positive, TP):指标不良且预后不良的患者；假阳性(false positive, FP):指标不良且预后良好的患者；敏感性(sensitivity, SE)=[TP/(TP+FN)] x100%;特异性(specificity, SP)=[TN/(TN+FP)]×100%。准确率=TN+TP/116。错误率=FP/116。 3.统计学方法所有数据采用SPSS13.0统计学软件进行分析,两个独立样本率比较采用x2检验。P0.05为差异有统计学意义。 [结果] 1.两组头颅CT中脑水平前后径与横径的比值对昏迷患者的预后良好率相比较,经四格表资料的x2验检,差异有统计学意义(x2=25.119,P=0.000)。 2.116例昏迷患者脑电图有无反应性的预后良好率相比较,经四格表资料的x2检验,差异有统计学意义(x2=54.296,P=0.000)。 3.脑电图反应性与头颅CT中脑前后径与横径的比值联合分为四组,经R×C表资料的x2检验,四组患者的预后良好率比较,差异有统计学意义(x2=58.507,P=0.000)。 4.EEG反应性检测的敏感性83.67%、特异性85.07%、准确率84.48%、错误率8.62%,头颅CT检查的敏感性75.51%、特异性71.64%、准确率73.28%、错误率16.37%；EEG反应性联合头颅CT检测的敏感性91.42%、特异性89.58%、准确率90.36%、错误率5.88%。 [结论] 1.脑电图反应性及中脑形态与重型颅脑损伤昏迷患者的预后有相关性,可应用其对患者的预后进行有效评估。 2.脑电图反应性与头颅CT中脑形态联合应用可以有效地对重型颅脑损伤昏迷患者的预后进行评估。
[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.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R651.15

【参考文献】