纳洛酮治疗重型颅脑损伤疗效分析

近年来,国内外大量研究证明颅脑损伤后脑组织中内源性阿片肽含量异常改变参与继发性脑损伤发病过程[1].纳洛酮是一种人工合成的阿片受体拮抗剂,它能有效阻断急性颅脑损伤后内源性阿片肽含量异常增高所致的继发性脑损害[2].     

大剂量纳洛酮治疗小儿重型颅脑损伤的临床研究

目的 探讨大剂量纳洛酮对小儿重型颅脑损伤患者的治疗作用。方法 大剂量纳洛酮治疗小儿重型颅脑损伤患者53例与同等条件下但未用纳洛酮治疗的同类患者53例比较。结果 纳洛酮实验组恢复良好26例(49.1％),死亡6例(11.3％),觉醒天数为(11.73±6.56)(n=45);对照组分别为16例(30.2％)及14例(26.4％),觉醒天数为(17.7±8.35)(n=35);两组比较均有显著性差异(P<0.05);实验组血浆β-内啡肽均值较对照组下降明显(P<0.01)。结论 小儿重型颅脑损伤早期应用大剂量纳洛酮治疗可降低死亡率,提高恢复良好率,缩短昏迷时间,治疗过程中未见毒副作用。     

纳洛酮治疗重型颅脑损伤效果观察

重症颅脑损伤患者的脑脊液中β-内啡肽和强啡肽含量显著升高,这可能与患者的预后有密切关系。纳洛酮作为体内阿片受体的竞争性拮抗剂,被广泛应用于颅脑损伤的治疗中,在减少继发性脑损害,促进神经功能恢复以及改善患者预后等方面,发挥重要的临床作用。2011-02—2012-02我院诊治的重型颅脑损伤患者早期给予纳洛酮治疗,取得较好临床效果,现将汇报如下。     

颅骨修补对重型颅脑损伤术后意识恢复的影响

目的探讨颅骨修补对重型脑外伤去骨瓣减压术后长期昏迷病人的影响。方法将47例重型脑外伤去骨瓣减压术后3个月内未清醒(GSC≤8)病人分2组:颅骨修补组20例,对照组27例。颅骨修补组在颅骨修补术后第3个月和第6个月分别进行GOS评分,对照组在对应时间进行随访评估,评估分为有效(GOS 3~5),无效(GOS=2),死亡(GOS=1)。结果颅骨修补组总有效率高于对照组(P<0.05);2组病死率比较无明显差异(P>0.05)。颅骨修补组修补术后第6个月评估,去骨瓣术前一侧瞳孔散大病人有效率高于两侧瞳孔散大病人(P<0.05),两侧颅骨缺损有效率高于一侧颅骨缺损病人(P<0.05),术前GCS评分高的病人有效率高于GCS评分低的病人(P<0.05);性别和修补材料对预后的影响差异无统计学意义(P>0.05)。结论颅骨修补有利于脑外伤术后长期昏迷病人的清醒。     

纳洛酮在重型颅脑损伤救治中的应用研究

急性重度颅脑损伤后，机体释放出大量内源性阿片肽，其中β～内啡肽(β～EP)产生广泛的病理、生理效应，加重继发性脑损害，纳洛酮为阿片受体特异性拮抗剂，与阿片样受体的亲和力比与β-内啡肽等吗啡样物质大，能竞争性阻止并取代β-内啡肽类吗啡样物质的作用，达到对受损脑组织的保护作用。国内对部分学通过实验证明其对脑损伤具有良     

纳洛酮治疗重型颅脑损伤大剂量与小剂量的比较

纳洛酮小剂量(0.4～0.8mg)为常用量,肌注或静脉注射能迅速翻转吗啡的作用,大剂量(4.8～16mg)能有效增加呼吸频率,促使昏迷清醒.我院自1999年9月至2001年9月收治重型颅脑损伤病人160例,随机分为两组,分别用大剂量与小剂量纳洛酮治疗重型颅脑损伤各80例,经临床治疗观察.     

早期应用亚低温联合纳洛酮治疗重型颅脑损伤的疗效观察

目的探讨早期应用亚低温联合纳洛酮治疗重型颅脑损伤的临床效果。方法选取2006-12—2011-12在我院接受治疗的重型颅脑损伤患者(GCS计分≤8分)120例,随机分为治疗组和对照组各60例。对照组常规治疗,治疗组在常规治疗的基础上加用亚低温与纳洛酮进行联合治疗。结果治疗组的治疗效果明显优于对照组,治疗组的病死率20.0%,与对照组的31.7%相比,差异有统计学意义(P<0.05)。治疗后的第7、21天,治疗组GCS评分均明显高于对照组,差异有统计学意义(P<0.05)。治疗后3个月GOS评定,治疗组生存质量明显优于对照组,差异具有统计学意义(P<0.05)。结论早期给予患者亚低温与纳洛酮联合治疗重型颅脑损伤,能降低病死率,有效改善患者的GCS评分,加快恢复进程,提高患者的生存质量。     

Quantitative pupillometry in patients with traumatic brain injury and loss of consciousness: A prospective pilot study

ObjectiveLoss of consciousness (LOC) is a hallmark feature in Traumatic Brain Injury (TBI), and a strong predictor of outcomes after TBI. The aim of this study was to describe associations between quantitative infrared pupillometry values and LOC, intracranial hypertension, and functional outcomes in patients with TBI.MethodsWe conducted a prospective study of patients evaluated at a Level 1 trauma center between November 2019 and February 2020. Pupillometry values including the Neurological Pupil Index (NPi), constriction velocity (CV), and dilation velocity (DV) were obtained.ResultsThirty-six consecutive TBI patients were enrolled. The median (range) age was 48 (range 21–86) years. The mean Glasgow Coma Scale score on arrival was 11.8 (SD = 4.0). DV trichotomized as low (<0.5 mm/s), moderate (0.5–1.0 mm/s), or high (>1.0 mm/s) was significantly associated with LOC (P = .02), and the need for emergent intervention (P < .01). No significant association was observed between LOC and NPi (P = .16); nor between LOC and CV (P = .07).ConclusionsOur data suggests that DV, as a discrete variable, is associated with LOC in TBI. Further investigation of the relationship between discrete pupillometric variables and NPi may be valuable to understand the clinical significance of the pupillary light reflex findings in acute TBI.     

Predicting neurosurgical clearance in the polytrauma patient with concomitant traumatic brain injury

The goal of this study is to develop a model based on previously used prognostic predictors in traumatic brain injury (TBI) patients with polytrauma, which will facilitate the decision-making of whether to clear these patients for non-cranial surgery. Data of eligible patients was obtained from a trauma database at a Level I trauma and academic tertiary referral center in the United States. The number of days seen by the neurosurgical service prior to clearance, injury severity score (ISS), post-trauma day 0 (PTD 0) of Glasgow Coma Score (GCS), intracranial pressure (ICP) score and computed tomography (CT) score, as well as the changes in GCS, ICP score and CT score between PTD 0 and day of clearance were the variables used in developing the model. The Neurosurgical Clearance Model (NCM) was developed using data from 50 patients included in the study. Patients were cleared by neurosurgeons 1.6 days later than it would appear possible based on a retrospective review of the patients’ clinical conditions. A single model equation was developed, the ultimate result of which is a clearance probability value. The best cutoff clearance probability value was found to be 0.584 (or 58.4%) using Receiver Operator Characteristic curve analysis. Our data suggests that neurosurgeons are risk-averse in clearing polytrauma patients for non-cranial surgery. This pilot NCM, if reproduced and validated by other groups and in larger prospective studies, may become a useful tool to assist clinicians in this often-difficult decision-making process.     

Neural oscillations track recovery of consciousness in acute traumatic brain injury patients

Electroencephalography (EEG), easily deployed at the bedside, is an attractive modality for deriving quantitative biomarkers of prognosis and differential diagnosis in severe brain injury and disorders of consciousness (DOC). Prior work by Schiff has identified four dynamic regimes of progressive recovery of consciousness defined by the presence or absence of thalamically‐driven EEG oscillations. These four predefined categories (ABCD model) relate, on a theoretical level, to thalamocortical integrity and, on an empirical level, to behavioral outcome in patients with cardiac arrest coma etiologies. However, whether this theory‐based stratification of patients might be useful as a diagnostic biomarker in DOC and measurably linked to thalamocortical dysfunction remains unknown. In this work, we relate the reemergence of thalamically‐driven EEG oscillations to behavioral recovery from traumatic brain injury (TBI) in a cohort of N = 38 acute patients with moderate‐to‐severe TBI and an average of 1 week of EEG recorded per patient. We analyzed an average of 3.4 hr of EEG per patient, sampled to coincide with 30‐min periods of maximal behavioral arousal. Our work tests and supports the ABCD model, showing that it outperforms a data‐driven clustering approach and may perform equally well compared to a more parsimonious categorization. Additionally, in a subset of patients (N = 11), we correlated EEG findings with functional magnetic resonance imaging (fMRI) connectivity between nodes in the mesocircuit—which has been theoretically implicated by Schiff in DOC—and report a trend‐level relationship that warrants further investigation in larger studies.     

香丹注射液治疗急性重型颅脑损伤的内皮素含量与临床疗效观察

目的观察丹参治疗急性重型颅脑损伤后的血浆内皮素(ET)含量变化与临床疗效的关系。方法按标准选取急性重型颅脑损伤病人30例,随机分成对照组和试验组。对照组行常规治疗,试验组在常规治疗基础上加用香丹注射液治疗。治疗前和治疗后24小时、48小时、72小时、1周及2周分别采取肱静脉血,采用非平衡法测血浆内皮素含量,检测试验组病人的血压,治疗后1、3、7天两组病人行CT检查。两组病人分别于治疗前和治疗后3天、1周分别行格拉斯哥昏迷评分(GCS),比较两组的疗效。结果治疗后试验组血浆ET含量明显低于对照组,GCS高于对照组,差异均有统计学意义(P<0.05),治疗前后血压变化不明显(P>0.05),两组病人头CT均未见脑出血增加。结论丹参对急性重型颅脑损伤病人具有明显的临床治疗效果。     

Effect of progesterone administration on prognosis of patients with diffuse axonal injury due to severe head trauma

Objective

Severe traumatic brain injury (TBI) has a major role in mortality rate among the other types of trauma. The aim of this clinical study was to assess the effect of progesterone on the improvement of neurologic outcome in patients with acute severe TBI.

Methods

A total of 76 patients who had arrived within 8 h of injury with a Glasgow Coma Score ≤8 were enrolled in the study. In a randomized style 38 received progesterone (1 mg/kg per 12 h for 5 days) and 38 did not.

Results

There was a better recovery rate and GOS score for the patients who were given progesterone than for those in the control group in a 3-months follow-up period (50% vs. 21%); subgroup analysis showed a significant difference in the percentage of favorable outcome between the two groups with GCS of 5–8 (p = 0.03).

Conclusion

The use of progesterone may significantly improve neurologic outcome of patients suffering severe TBI up to 3 months after injury, especially those with 5 ≤ GCS ≤ 8, providing a potential benefit to the treatment of acute severe TBI patients. Considering this drug had no significant side effects, so progesterone could be used in patients with severe TBI as a neuro-protective drug.     

卒中后抑郁与脑损伤部位相关性的临床研究

目的探讨不同的脑损伤部位与脑卒中后抑郁病变的关系,探讨PSD的现况以及对结局的影响。方法收集2010年09月～2011年09月期间河北联合大学附属医院神经内科脑卒中患者300例,通过颅脑CT或MRI进行卒中病灶定位,采用Hamilton抑郁量表对卒中患者在发病14±2d及90±7d进行抑郁及程度的评价。对收集患者的相关临床指标如美国国立卫生院神经功能缺损评分(NIHSS)、改良Rankin量表评分(MRS)、简易精神状态检查表(MMSE)评分等相关因素进行统计分析。结果 140例脑卒中患者合并PSD,总发生率为46.67%,其中轻中度抑郁占46.00%,重度抑郁占0.67%;多发性、左侧半球、额颞叶、基底节区脑卒中患者PSD发生率高。结论脑卒中患者神经功能缺损程度评分越高,其患抑郁的程度也就越高。PSD发生与卒中类型无关,而与卒中部位、卒中残疾程度等因素有关。     

七叶皂苷钠对大鼠弥漫性脑损伤合并二次损伤后脑组织ET和NO含量的影响

目的观察七叶皂苷钠对大鼠弥散性脑损伤合并二次脑损伤后内皮素(ET)和一氧化氮(NO)等指标的影响,进一步探讨其作用机制及对弥漫性脑损伤合并二次脑损伤的治疗作用。方法 105只SD大鼠分成3组,分别为假手术组、模型组、治疗组。治疗组在1h、24h和48h腹腔注射2.5mg/kg的七叶皂苷钠。模型组在相同时间腹腔注射等量的生理盐水。治疗组和模型组每天注射并饲养10d将各组大鼠断头处死,迅速剥离额叶皮质40mg,匀浆,离心取上清,采用放射免疫法测定ET,硝酸还原酶法测NO。结果与假手术组比较,模型组大鼠脑组织ET和NO水平显著升高(P<0.05);与模型组比较,七叶皂苷钠治疗组大鼠脑组织ET和NO水平显著下降(P<0.05)。结论七叶皂苷钠可通过清除氧自由基和稳定血管内皮细胞等机制,对弥漫性脑损伤合并二次脑损伤发挥保护神经组织的作用。     

手厥阴经电刺激对脑性昏迷患者促醒作用的初步研究

目的 研究手厥阴经电刺激对脑性昏迷患者的促醒作用及机制。方法 20例脑性昏迷的患者随机分为对照组（n=10）和治疗组（n=10）,对照组给以常规治疗,治疗组即在常规治疗的基础上进行手厥阴经电刺激。在第一次治疗前,对两组病人均行经颅多普勒检查患者椎基底动脉的收缩期峰值血流速度（systolic velocity,Vs）、舒张期血流速度（diastolic velocity,Vd）、平均血流速度（meanvelocity,Vm）、搏动指数（pulsitility index,PI）。检测结束后立即给以治疗组病人手厥阴经电刺激30min,刺激结束后在同一体位,同一条件下行第二次检测。对比刺激前后即时的血流变化情况。每天给予手厥阴经电刺激30min,持续电刺激1个月后再次对对照组及刺激组进行相同TCD指标的检测,比较检测结果。1个月后两组治疗相同。对比治疗3（个月时的GCS评分、神经功能恢复情况和语言功能情况。结果 刺激组患者手厥阴经电刺激对脑性昏迷患者椎-基底动脉血流速度异常状态有明显的即刻效应。持续刺激1个月后,治疗组血流速度较对照组有显著提高。伤后3个月时,刺激组患者GCS评分明显优于对照组,刺激组患者语言功能评分和生活质量评分也明显优于非刺激组。结论 手厥阴经电刺激能提高脑性昏迷患者椎-基底动脉的血流速度,对于促进脑性昏迷患者的苏醒有积极的治疗作用．     

Trends in epidemiological and clinical characteristics in severe traumatic brain injury: Analysis of the past 25 years of a single centre data base

ObjectiveTo describe the demographic and clinical profiles of a cohort of environmentally representative severe traumatic brain injury (TBI) cases collected for the past 25 years and to analyse the changes that occurred by dividing the analysis period into 3 equal time periods.Material and methodsThis was an observational cohort study of consecutive adult patients (>14 years of age) with severe closed TBI (Glasgow Coma Scale score [GCS] ≤ 8) who were admitted during the first 48 h after injury to the 12 de Octubre hospital from 1987 to 2012. The most relevant epidemiological and clinical variables reported in the literature were defined and compared in 3 equal time periods (1987–1995, 1996–2004 and 2005–2014).ResultsThere was a 13% reduction in the frequency of severe TBI from the first to the last time period. An increase in the mean age from 35 to 43 years was observed, whereas the frequency of severe TBI according to sex remained approximately the same during the last decades of life. A distinct change was observed in the injury mechanism; traffic accidents decreased from 76% to 55%, particularly those involving 4-wheeled vehicles. However, falls increased significantly, especially in older women, and contusion and subdural haematoma were the most frequent structural injuries. Motor scores could not be reliably assessed for the last time period because of early intubation and sedative drug use.ConclusionsTBI epidemiology in Western countries has changed. This trend was also observed in our environment as an increase in mean age, which reflected the increase in falls among elderly patients.     

Time course of cell death induced by traumatic brain injury on mice

研究背景：尽管脑外伤（traumatic brain injury, TBI）后神经细胞死亡的各种分子机制研究取得了很大进展,但由于细胞死亡标记方法的限制,使得TBI后细胞死亡发生的时程变化规律以及TBI引起神经细胞死亡的确切机制（占主导的是机械外力直接破坏还是继发的程序性控制）仍然不明。 目的：发现能够在TBI早期至晚期全程标记在体细胞死亡的标记物及使用方法,阐明TBI引发的神经细胞死亡规律并探讨TBI引起的神经细胞死亡机制,为临床救治TBI病人提供最佳时间窗口。 实验设计,时间及实施：在活体TBI动物模型上使用碘化丙啶(propidium iodide, PI)作为神经细胞死亡标记物,采用随机分组的方法进行实验,即将体重均衡的65只健康昆明小鼠随机分成假手术组,TBI后0 min、10 min、30 min、1 h、3 h、6 h、12 h、24 h、48 h、72 h、7 day、14天和21天组。整个实验于2007年9月至2008年12月在苏州大学衰老与神经疾病重点实验室完成。 材料：昆明小鼠（由苏州大学实验动物中心提供）;PI (B1221)购买于Sigma公司;定量脑皮质自由落体打击（controlled cortical impact, CCI）装置;体视学显微镜及软件（Nikon公司）。 实验方法：通过预实验证明,动物处死前1 h腹腔注射进行PI标记的方法最为简便,并且能够显示细胞死亡的形态学变化。因此,按照实验分组使用CCI装置建立定量TBI动物模型,动物处死前1 h腹腔注射PI（1μg/g）,取脑后连续冰冻切片,采用体视学显微镜及软件对每张切片中的伤侧全部脑片随机5个视野进行PI阳性细胞计数。实验结果采用ANOVA并进行t检验。 结果：PI 阳性细胞计数结果显示,与假手术组和TBI后0 min 组比较,其他各个实验组均可见数量不等的PI阳性细胞。TBI后10 min和30 min时间点仅发现有少量PI阳性细胞,之后开始大量增加,尤其是在TBI后1 h到6 h这段时间PI阳性细胞数量上升最快,而在TBI后24 h和48 h时间点PI阳性细胞数量达到高峰,之后逐渐减少,在TBI后21天仍可见有PI阳性细胞。 结论：PI可以作为在体细胞死亡标记物;TBI所引起的神经细胞死亡除了机械性外力直接作用外,主要是继发的程序性死亡（包括凋亡、自噬性细胞死亡,甚至程序性坏死）;TBI后48 h内是临床保护神经元、救治TBI病人的关键时期。