预测急性闭合性颅脑外伤预后的临床因素探讨

目的　探讨影响脑外伤患者预后转归的临床因素，建立预测预后的回归模型。方法　采用 Ｌｏｇｉｓｔｉｃ 回归分析方法对１１２ 例急性闭合性颅脑外伤患者的预后进行分析。结果　单因素分析表明，患者瞳孔情况、昏迷病程、伤后昏迷时间长短、 Ｇ Ｃ Ｓ 评分、硬膜下和脑实质内血肿及弥漫性轴索损伤的存在与否、血肿量的多少等对预后有重要影响；而经多因素分析后只有入院时 Ｇ Ｃ Ｓ 评分、瞳孔情况和昏迷病程与预后有显著联系，并建立了具较高灵敏度和特异度的预测预后的多因素回归模型。结论　只要建立科学的多元回归模型，是可以在颅脑外伤的早期利用某些临床资料初步预测预后。     

急性创伤昏迷大鼠中脑calpain Ⅱ、Nach6的表达

目的通过随机分组研究急性创伤昏迷大鼠中脑钙蛋白酶Ⅱ（CalpainⅡ）及电压门控钠通道亚型（Nach6）的早期表达变化。方法雄性sD大鼠12只，随机分为两组：假手术对照组（n=6）；急性创伤昏迷组（n=6）。建立急性创伤昏迷大鼠模型，1h后通过实时定量PCR法检测中脑钙蛋白酶Ⅱ及电压门控钠通道亚型（Nach6）变化。结果逆转录酶-多聚酶链反应（RT-PCR）法结果显示钙蛋白酶Ⅱ在创伤昏迷组的中脑表达相对含量增加（P〈0．01），电压门控钠通道亚型（Nach6）在创伤昏迷组的中脑组织表达相对含量增加（P〈0．05）。结论急性创伤昏迷早期钙蛋白酶Ⅱ激活、钠离子内流导致中脑神经细胞及胶质细胞损伤可能为急性创伤昏迷早期分子生物学机制之一。     

重型颅脑损伤昏迷患者的清醒预测模型

目的 探讨早期预测评估重型颅脑损伤昏迷患者清醒概率的方法,开发预测清醒概率的模型. 方法 回顾性分析南方医科大学附属花都医院神经外科自2010年5月至2012年7月间收治的263例重型颅脑损伤昏迷患者的临床资料,多分类Logistic回归分析与患者清醒预后相关的多种因素,并建立预测清醒概率的模型. 结果 多分类Logistic回归显示年龄、入院时瞳孔对光反射、运动格拉斯哥评分(mGCS)、CT示脑干是否受压,治疗后的睁眼时间和脑缺血体积百分比均为重型颅脑损伤昏迷患者清醒的独立预测因子,Pearson残差评估显示预测模型的拟合效果较佳. 结论 本预测模型有较好的拟合效果,所需预测因子的数据易于获得,普遍适用于基层医院,对重型颅脑损伤昏迷患者早期的临床决策有重要参考价值.     

基底节区出血术后昏迷时间的预后分析

目的探讨基底节区出血手术治疗后患者昏迷时间的影响因素。方法对三种手术方式治疗基底节区出血45例患者的临床资料进行回顾分析,确定病人清醒,有遵嘱动作为终点事件。采用Kaplan-Meier法进行单因素分析,Cox回归模型进行多因素分析。结果单因素分析显示血肿量、手术方式、发病到手术的时间、术前GCS评分、是否合并脑疝以及术后是否气管切开是影响患者术后的昏迷时间的因素(P0.05)。多因素分析显示血肿量、发病到手术的时间及是否合并脑疝是影响基底节区出血术后昏迷的独立危险因素。结论患者发病24h内采用小骨窗显微镜下手术清除血肿,患者昏迷时间短,预后好。     

P300在鉴别闭合性颅脑外伤患者真假昏迷的价值

目的：研究P300在鉴别闭合性颅脑外伤患者真假昏迷的价值。方法：将237例闭合性颅脑外伤患者根据其有否昏迷史分为有昏迷组,无昏迷组,假昏迷组及不详组,并对各组视觉（图像）刺激诱发的异常P300波潜伏期和波幅进行比较分析。结果：昏迷组与无昏迷组的P300潜伏期和波幅有非常显著的差异（P＜0．001）;昏迷组与假昏迷的P300潜伏期和波幅亦有非常显著的差异（P＜0．001）;但无昏迷组与假昏迷组间无明显差异（P＞0．05）;昏迷史不详组与无昏迷组间有显著差异（P＜0．05）。结论P300波的变化可作为判断闭合性颅脑外伤患者有无昏迷的一项客观指标,在外伤事故鉴定中有重要的参考价值。     

昏迷患者脑电图构型的临床意义

探讨昏迷病人脑电图构型昏迷程度及预程度及预后之间接关系。方法对过去 １７上间８４例昏迷病人的脑电图进行研究。结果脑电图显示广泛性慢波，弥漫性波一侧偏胜，β－昏迷，纺锤－昏迷、α－昏迷，三相波，平胆波，广泛性周期性复合慢波，周期性一侧痫样主电，爆发－抑制（１）例。结论：分析昏迷病人的脑电色型对确定昏迷程度及判断预后有一定意义。     

老年脑出血后患者昏迷苏醒时间的多因素分析

目的 探讨影响老年脑出血后患者昏迷苏醒时间的相关因素。方法 选取本院2012年6月～2015年10月收治的82例老年脑出血昏迷患者为研究对象,以性别、年龄、术前格拉斯哥昏迷评分(GCS, Glasgow Coma Scale)、脑血肿量、血肿是否破入脑室、高血压病史、是否气管切开、治疗、并发感染等为自变量,昏迷至苏醒的时间为因变量,先进行单因素分析,对有统计学意义的变量采用Cox回归模型进行多因素分析。结果 单因素分析显示,术前GCS评分≤5分、脑血肿量>50 mL、血肿破入脑室、高血压病史、气管切开、未采用盐酸纳洛酮联合正中神经电刺激治疗、并发感染的患者昏迷苏醒时间更长(P<0.05); 多因素分析显示,血肿破入脑室、气管切开、并发感染是导致昏迷苏醒时间延长的危险性因素(P<0.05),术前GCS评分高与采用盐酸纳洛酮联合正中神经电刺激治疗可能是昏迷苏醒时间的保护性因素(P<0.05)。结论 血肿破入脑室、气管切开、并发感染、术前GCS评分低是导致老年脑出血患者昏迷苏醒时间延长的主要影响因素,应尽量选择盐酸纳洛酮联合正中神经电刺激治疗方案,强化无菌医疗操作,加强抗感染护理干预,以缩短苏醒时间及改善预后。     

昏迷病人的脑电图表现及与预后的关系

目的：探讨昏迷病人的脑电图表现和预后之间的关系。方法：对１６９例昏迷病人的脑电图进行回顾性分析,并将其与临床结局作对照。结果：脑电图慢波型昏迷１２０例中死亡２３例（１９．１％）;α昏迷型１１例中死亡９例（８１．８％）;β昏迷型３例和纺儿锤昏迷型２例均存活;发作波型昏迷１３例中死亡２例（１５．３％）;平坦波型昏迷２０例中死亡１７例（８５％）。结论：脑电图可作为判断昏迷病人临床预后的参考指标。平坦波昏     

外伤性急性颅内血肿的治疗

一、临床资料共１００例，年龄３～７０岁。受伤至入院时间１小时至３天。有原发性昏迷８６例，无昏迷和继发性昏迷１４例，来院时意识清楚３８例，轻度昏迷１４例，中度昏迷２６例，重度昏迷２２例；其中瞳孔散大２３例（双侧瞳孔散大达２小时以上者５例），肢体瘫痪２５...     

昏迷的诊断和治疗

昏迷是内科最常见的急诊之一,有关诊断和治疗已见于一般书籍和文献。本文从医疗实践出发,重点讨论昏迷的诊断步骤、病因和分类以及治疗。昏迷的定义昏迷是高级神经活动严重抑制的一种临床表现,其特点表现为意识丧失,对各种刺激失去正常反应,随意运动和感觉丧失。昏迷和昏厥不同,昏迷时意识丧失持久而不易迅速恢复。昏迷必须与去大脑皮层综合征相区别,二者可能为同一病因所致中枢神经系统的严重损害的不同病理     

Coexisting alpha pattern coma, theta pattern coma and spindle coma

Abnormal ectopic rhythms, such as alpha-theta activities and spindles, occur in comatose patients. A case is presented in which the EEG of a comatose patient showed coexisting alpha-theta pattern activities and spindles. It is concluded that the coexistence of these rhythmic patterns in the EEG of a comatose patient implies continued physiologic functioning of a thalamocortical system deafferented by brainstem dysfunction and a lesser degree of cortical dysfunction.     

高颈段脊髓电刺激促醒颅脑创伤昏迷一例并文献复习

目的 研究高颈段脊髓电刺激对颅脑创伤昏迷的促醒作用.方法 观察1例重型颅脑创伤患者高颈段脊髓电刺激术后清醒时间、脑电图、诱发电位及脑血流的变化.结果 患者术后2个月逐渐清醒,脑电图逐渐转为正常α节律,诱发电位潜伏期延长逐渐改善,脑血流明显增加.结论 高颈段脊髓电刺激可能通过增加脑血流、恢复正常的神经电生理活动促醒颅脑创伤昏迷患者.

Abstract：

Objective To study the awoking effect of high cervical spinal cord stimulation on comatose patients with traumatic brain injury.Methods Recovery time,electroencephalogram(EEG),evoked patentials,cerebral blood perfusion after cervical spinal cord stimulation in a comatose patient were investigated.Results The patient emerged form conla at 2 months after spinal cord stimulation treatment.EEG gradually turned into a normal(rhythm,evoked potentials latency improved,and cerebral blood perfusion increased significantly.Conclusions High cervical spinal cord stimulation exerts its beneficial effects to comatose patients with traumatic brain injury by increasing cerebral blood perfusion and restoring normal cerebral electrical activity.     

Mu and alpha rhythm in comatose children

Three anoxic comatose children had EEG alpha-like activity and in two of them mu rhythm was recorded. The paradoxical appearance of these electrical activities in comatose children seems to indicate a grave prognosis. A possible role for barbiturate treatment in this phenomenon is not excluded.     

N18 in median somatosensory evoked potentials: a new indicator of medullary function useful for the diagnosis of brain death

OBJECTIVES: To record N18 in median somatosensory evoked potentials (SEPs) for deeply comatose or brain dead patients and to demonstrate the usefulness of N18 for the diagnosis of brain death in comparison with auditory brain stem responses (ABRs) and P13/14 in median SEPs, which have been conventionally used as complementary tests for the diagnosis of brain death. METHODS: Subjects were 19 deeply comatose or brain dead patients. Thirteen recordings were performed in deeply comatose but not brain dead conditions, and 12 recordings were performed in brain death. N18 was evaluated in the CPi-C2S lead (or other scalp-C2S leads) to obtain a flat baseline. RESULTS: N18 was preserved in 12 of 13 non-brain dead comatose recordings whereas it was completely lost for all of the 12 brain death recordings. P13/14 in median SEPs was preserved for all the comatose recordings, whereas apparent P13/14-like potentials, usually of low amplitude, were seen in nine of 12 brain death recordings-that is, frequent false positives. The ABRs already showed features which were characteristic for brain death (loss of components other than wave 1 or small wave 2) for four comatose recordings, in three of which N18 was preserved. The last result not only corresponds with the fact that ABRs can evaluate pontine and midbrain functions and not medullary function, but further supports the medullary origin of N18. In the four patients followed up for the course of progression from coma to brain death, N18s preserved in normal size during the comatose state were completely lost after brain death was established. CONCLUSIONS: The N18 potential is generated by the cuneate nucleus in the medulla oblongata in the preceding studies. N18 is suggested to be a promising tool for the diagnosis of brain death because there were no false positives and rare false negatives in the present series for detecting the remaining brain stem function.     

The Utility of EEG,SSEP, and Other Neurophysiologic Tools to Guide Neurocritical Care

Neuromonitoring is an emerging field that aims to characterize real-time neurophysiology to tailor therapy for acute injuries of the central nervous system. While cardiac telemetry has been used for decades among patients requiring critical care of all kinds, neurophysiology and neurotelemetry has only recently emerged as a routine screening tool in comatose patients. The increasing utilization of electroencephalography in comatose patients is primarily due to the recognition of the common occurrence of nonconvulsive seizures among comatose patients, the development of quantitative measures to detect regional ischemia, and the appreciation of electroencephalography phenotypes that indicate prognosis after cardiac arrest. Other neuromonitoring tools, such as somatosensory evoked potentials have a complementary role, surveying the integrity of the neuroaxis as an indicator of prognosis or illness progression in both acute brain and spinal injuries.     

昏迷患者的脑干听觉诱发电位与耳蜗电图联合研究

预测及判断昏迷患者的预后。方法对２０例昏迷患者进行脑干听觉诱发电位（ＢＡＥＰ）与耳蜗电图（ＥｃｏｃｈＧ）联合测试，同时用格拉斯哥昏迷量表（ＧＣＳ）评分。结果这种联合测试可使ＢＡＥＰ的Ⅰ波分辨率提高１２．５％。ＢＡＥＰ示脑干严重病损者，预后肯定不良，无假阳性；而ＢＡＥＰ正常者则因多种原因（如仅早期检测１次等）而有一定的假阴性。ＧＣＳ无假阴性，但因病因关系有一定假阳性。结论ＢＡＥＰ预测昏迷患者的预后时最好同时测试ＥｃｏｃｈＧ，有助于临床提高其判断的准确性     

Prevalence of nonconvulsive status epilepticus in comatose patients

BACKGROUND: Nonconvulsive status epilepticus (NCSE) is a form of status epilepticus (SE) that is an often unrecognized cause of coma. OBJECTIVE: To evaluate the presence of NCSE in comatose patients with no clinical signs of seizure activity. METHODS: A total of 236 patients with coma and no overt clinical seizure activity were monitored with EEG as part of their coma evaluation. This study was conducted during our prospective evaluation of SE, where it has been validated that we identify over 95% of all SE cases at the Medical College of Virginia Hospitals. Only cases that were found to have no clinical signs of SE were included in this study. RESULTS: EEG demonstrated that 8% of these patients met the criteria for the diagnosis of NCSE. The study included an age range from 1 month to 87 years. CONCLUSION: This large-scale EEG evaluation of comatose patients without clinical signs of seizure activity found that NCSE is an underrecognized cause of coma, occurring in 8% of all comatose patients without signs of seizure activity. EEG should be included in the routine evaluation of comatose patients even if clinical seizure activity is not apparent.     

The prognostic value of evoked responses from primary somatosensory and auditory cortex in comatose patients.

OBJECTIVE: To evaluate somatosensory and auditory primary cortices using somatosensory evoked potentials (SEPs) and middle latency auditory evoked potentials (MLAEPs) in the prognosis of return to consciousness in comatose patients. METHODS: SEPs and MLAEPs were recorded in 131 severe comatose patients. Latencies and amplitudes were measured. Coma had been caused by transient cardiac arrest (n=49), traumatic brain injury (n=22), stroke (n=45), complications of neurosurgery (n=12) and encephalitis (n=3). One month after the onset of coma patients were classified as awake, still comatose or dead. Three months after (M3), they were classified into one of the 5 categories of the Glasgow outcome scale (GOS). RESULTS: At M3, 41.2% were dead, 47.3% were conscious (GOS 3-5) and 11.5% had not recovered consciousness. None of the patients in whom somatosensory N20 and auditory Pa were absent did return to consciousness and in the post-anoxic group, reduced cortical amplitude too was always associated with bad outcome. Conversely, N20 and Pa were present, respectively, in 33/69 and 34/69 patients who did not recover. CONCLUSIONS: The prognostic value of SEPs and MLAEPs in comatose patients depends on the cause of coma. Measurement of response amplitudes is informative. Abolition of cortical SEPs and/or cortical MLAEPs precludes post-anoxic comatose patients from returning to consciousness (100% specificity). In any case, the presence of short latency cortical somatosensory or auditory components is not a guarantee for return to consciousness. Late components should then be recorded.     

Prognostic value of myoclonus status in comatose survivors of cardiac arrest

Generalized myoclonus status is common in comatose patients after cardiac resuscitation, but its prognostic value is uncertain. We studied the clinical, radiologic, and pathologic findings in 107 consecutive patients who remained comatose after cardiac resuscitation. Myoclonus status was present in 40 patients (37%). Features more prevalent in patients with myoclonus status were burst suppression on electroencephalograms, cerebral edema or cerebral infarcts on computed tomography scans, and acute ischemic neuronal change in all cortical laminae. All patients with myoclonus status died. Of 67 patients without myoclonus, 20 awakened. We conclude that myoclonus status in postanoxic coma should be considered an agonal phenomenon that indicates devastating neocortical damage. Its presence in comatose patients after cardiac arrest must strongly influence the decision to withdraw life support.     

Monitoring of the comatose patient

Monitoring of comatose patients involves a close followup of clinical findings and a number of various techniques. These techniques may be differentiated in invasive and non invasive techniques. The benefit of these techniques is controversial as to their effect on the actual therapy of the comatose patient. The benefit of sedation beyond the point of what is required for adequate sedation is questioned, as it makes clinical observation useless. Since there is no evidence that any technical monitoring is as sensitive and reliable as clinical monitoring, the reliance on only technical monitoring needs to be discussed.