重型颅脑损伤胰岛β-细胞功能与胰岛素抵抗研究

目的探讨重型颅脑损伤性高血糖患者血浆肿瘤坏死因子一α（TNF-α）与胰岛β细胞功能不全和胰岛素抵抗之间的关系。方法观察我院近年来50例重型颅脑损伤性高血糖患者血浆TNF-α、稳态模式评估法胰岛素分泌指数（HOMA—β）、糖负荷30min后胰岛素增量和血糖增量比值（AINS30／AGLU30）和稳态模式评估法胰岛素抵抗指数（HOMA—IR），并分析血浆TNF．仅与HOMA—β、AINS30／AGLU30和HOMA-IR相关性。结果重型颅脑损伤性高血糖患者血浆TNF-α、HOMA—IR均显著高于正常对照组（P〈0．01），HOMA—β和AINS30／AGLU30均显著低于正常对照组（P〈0．01）。重型颅脑损伤性高血糖患者血浆TNF-α与HOMA—β和AINS30／AGLU30显著负相关、与HOMA—IR显著正相关（P〈0．01）。结论重型颅脑损伤性高血糖患者存在胰岛β-细胞功能不全和胰岛素抵抗，血浆TNF-α在创伤后糖代谢障碍中可能发挥重要作用。     

SPECT及SOD检测在颅脑损伤患者中的应用

目的探讨超氧化物歧化酶（SOD）及单光子发射计算机体层摄影（SPECT）在评价颅脑损伤后病情和预后中的作用。方法选择符合要求的颅脑损伤患者60例，按照GCS评分标准分成轻型损伤组45例，中型损伤组8例和重型损伤组7例。20例健康员工为对照组。对人选的所有对象进行SPECT、CT扫描和SOD检测，其中颅脑损伤患者在伤后24h内和2周后进行SPECT和CT检查，伤后12h、24h、36h、48h、72h、1周、2周、1月和2-月抽取外周静脉血测定SOD含量。并对所有患者在伤后6月按GOS评价预后。结果入院初和伤后2周，对颅脑损伤患者SPECT检出阳性率要明显高于CT检出阳性率（P〈0．01），尤其对轻型损伤的患者更是如此．SPECT检出的颅脑损伤病灶数也比CT多。外周血SOD含量在伤后24h显著下降（P〈0．05），其中中型和重型损伤组SOD值下降最明显，直到1月后其值才恢复正常；伤后24h外周血SOD值与入院时GCS评分及伤后6月GOS评分呈正相关（P〈0.05）。结论颅脑损伤后早期进行SPECT和SOD的检测可以评价病情等级并可以对预后情况最出初步估计。     

颅脑损伤后血清可溶性E-选择素水平变化及其意义

目的 研究颅脑损伤后血清可溶性E-选择素水平变化及其意义。方法 采用酶联免疫吸附法（ELISA）对30例重型颅脑损伤（GCS 3-8分）患者和25例轻-中型颅脑损伤（GCS 9-15分）患者伤后12、24、48、72和96h的血清可溶性E-选择素水平进行测定，伤后3个月按GOS评分评估预后，分析血清可溶性E-选择素水平变化与预后的关系。同时测定20例健康人血清可溶性E-选择素水平作为对照。结果 重型颅脑损伤组血清可溶性E-选择素水平明显高于正常对照组（P〈0．05），在伤后12和24h也明显高于轻-中型颅脑损伤组（P〈0．05）。伤后12h血清可溶性E-选择素水平〉60μg/L的病人预后明显不良（P〈0．05）。结论 血清可溶性E-选择素水平在颅脑损伤后明显升高．而且与预后相关。     

应激性高血糖对急性重型颅脑损伤预后的评估

目的探讨血糖在急性重型颅脑损伤病情评估及预后判断的临床价值。方法对150例既往无糖尿病的急性颅脑损伤患者均于入院时进行GCS评分,根据GCS评分分为轻中度颅脑外伤组(GCS 9~15分)和重度颅脑外伤组(GCS 3~8分),并对患者48h内的血糖变化进行检测,探讨伤后血糖水平与患者伤情、预后的关系。结果重度颅脑损伤组患者的平均血糖水平高于轻中度组(P<0.05),血糖>11.1 mmol/L颅脑损伤患者的病死率明显高于血糖<11.1 mmol/L者(P<0.05),死亡患者的血糖水平明显高于存活患者(P<0.05)。结论重度颅脑外伤患者急性期的血糖浓度是判断颅脑损伤的严重程度及近期预后的参考指标,可作为GCS评分外的辅助指标。     

急性颅脑损伤后血清S100B蛋白含量变化

目的研究血清中S100B蛋白含量变化与颅脑损伤患者病情的关系。方法应用电化学发光免疫法测定36例急性颅脑损伤患者伤后不同时间血清S100B蛋白含量变化，结合GCS评分进行分析，并与对照组（20例无神经系统疾病史者）进行比较。结果颅脑损伤后24、48、72h和1周患者血清S100B蛋白水平均较对照组明显升高（P〈0．01）；颅脑损伤越严重，S100B蛋白水平升高越明显．伤后早期（48h内）重型（GCS评分≤7分）者血清S100B蛋白水平明显高于中、轻型（GCS评分≥8分）者（P〈0．01）。结论急性颅脑损伤后血清S100B含量明显升高，并与患者病情密切相关。     

颅脑损伤后炎性细胞的变化及其与继发性脑损伤的关系

目的探讨颅脑损伤后患者外周血白细胞（WBC）及多形核嗜中性白细胞（PMN）的变化及其在继发性脑损害中的作用。方法选取伤后24h内入院的非手术治疗的颅脑损伤患者63例,于入院时、入院后24h、48h、72h及168h不同时间段采外周静脉血进行白细胞计数及分类,同时进行GCS评分,计算脑出血量及脑水肿体积,伤后6个月进行GOS评分,分析上述指标与WBC和PMN之间的关系。选取10例健康自愿者行WBC及PMN计数检查。结果颅脑损伤以后WBC及PMN先升高后下降,分别于伤后24h和48h达到高峰（P〈0.05）;伤后WBC及PMN与GCS评分呈负相关（P〈0.05）,GCS〈8分组WBC和PMN计数显著高于GCS≥8分组（P〈0.05）;颅脑损伤后脑出血量及脑水肿体积与WBC及PMN呈正相关（P〈0.05）;GOS评分与WBC及PMN呈负相关（P〈0.05）。结论颅脑损伤后WBC及PMN明显升高,且与伤情、出血量、水肿体积及预后有关,可能跟WBC及PMN对颅脑损伤后引起的继发性损害有关,WBC和PMN计数有助于对伤情、预后的判断。     

联合检测C-反应蛋白和IL-Iβ、IL-6对急性颅脑损伤预后的指导意义

目的探讨颅脑损伤急性期联合检测G反应蛋白（C-reactive protein，CRP）、白介素-1β（interleukin-1β）及白介素-6（interleukin-6）的急性变化与颅脑损伤程度和预后的关系。方法192例颅脑损伤患者依据格拉斯哥评分（Glasgow coma scale，GCS）、出院后3个月格拉斯哥预后评分（Glasgow outcome scale，GOS）依次分组，采用免疫比浊法及双抗体夹心ABC-ELISA法测定伤后24h内血清hCRP、IL-1β及IL-6的浓度。结果伤后24h内hCRP、IL-1β及IL-6升高，随着病情的好转逐渐下降，三者与GCS呈负相关（r=-0．162，P〈0．05），血清hCRP与IL-1β应用直线相关分析两者呈正相关（r=0．147，P〈0．05）。血清hCRP与IL-6应用直线相关分析两者呈正相关（r=0．196，P〈0．01），三项检测指标之间呈直线相关。GCS不同分组检测结果组间比较，差异有统计学意义（P〈O．05）。颅脑损伤急性期血清中hCRP、IL-1β及IL-6浓度在GOS评分分组后比较差异有统计学意义（P〈0．01）。结论血清中hCRP、IL-1β及IL-6是颅脑损伤患者急性期脑损伤敏感而特异的指标，联合检测对判断病情及预后、早期诊治继发性脑损害有重要意义。     

重型颅脑损伤后高血糖与预后的关系

目的探讨重度脑损伤后高血糖反应及与预后的关系。方法对165例重型颅脑损伤患者(GCS≤8分)入院后24 h内测定的空腹血糖值进行回顾性分析,比较高血糖组(血糖值> 6.11 mmol/L)与正常血糖组的GOS良好率和死亡率,同时比较高血糖组中不同GCS的血糖水平。结果高血糖组GOS良好率(21.7 %)低于正常血糖组(35.6 %),而死亡率(43.5 %)高于正常血糖组(26 %);高血糖组中GCS 3~5分组血糖值(12.37±2.27)mmol/L明显高于GCS 6 ~ 8分组(9.0±2.0)mmol/L。以上数据经统计学处理,差异均有显著性(P<0.05)。结论重型颅脑损伤病人早期因应激反应或损伤下丘脑、脑干等因素易出现血糖升高,伤情越重,血糖越高,且严重影响预后,过高血糖是导致伤者死亡的重要因素之一。     

中、重型颅脑损伤病人血糖、血肌酐的变化对疾病转归的影响

目的 探讨中、重型颅脑损伤病人血糖、血肌酐变化情况及其对病情转归的影响。方法 回顾性分析2015年10月至2018年1月收治的71例中、重型颅脑损伤的临床资料。伤后24 h、48 h、72 h、7 d、14 d、30 d监测血糖及血肌酐。伤后1年,按GOS评分评估预后。结果 伤后1年,预后良好23例（GOS评分4~5分,预后良好组）,预后不良48例（GOS评分1~3分,预后不良组）。两组病人血糖、血肌酐均先增高,后降低,伤后7 d达峰值。伤后24 h至伤后30 d,预后良好组血糖水平均明显低于预后不良组（P<0.05）。伤后24 h,预后良好组血肌酐水平明显高于预后不良组（P<0.05）;伤后48 h至伤后30 d,预后良好组血肌酐水平均明显低于预后不良组（P<0.05）。结论 中、重型颅脑损伤病人血糖、血肌酐水平变化与病人预后显著相关,伤后血糖、血肌酐升高越明显,预后越差。     

外伤性脑梗死与凝血功能障碍的关系及其对中、重度颅脑损伤患者预后的影响

目的探讨早期（伤后1周）外伤性脑梗死与凝血功能异常的关系,及其对中、重度颅脑损伤患者预后的影响。方法回顾性分析我科收治的218例中、重度颅脑损伤患者的临床资料,记录患者凝血功能各项指标以及入院时GCS评分、弥漫性血管内凝血（DIC）评分;伤后3个月采用GOS评分评估患者预后;使用Logistic回归分析颅脑损伤患者继发外伤性脑梗死的影响因素及凝血功能异常和外伤性脑梗死对患者预后的影响。结果本组患者中27例伤后1周出现外伤性脑梗死;伤后3个月,预后良好（GOS评分4~5分）178例,预后不良（GOS评分1~3分）40例。Logistic回归分析显示血小板计数〈100×109/L、凝血酶原时间延长超过3 s、D-二聚体〉0.4 mg/L、DIC评分≥5分是中、重度颅脑损伤患者继发早期PTCI的独立预测因子（P〈0.05）;同时,它们也是中、重度颅脑损伤患者预后不良的独立预测指标（P〈0.05）。结论监测中重度颅脑外伤患者的凝血功能对于指导治疗及判断预后是帮助。     

简易运动评分与GCS对颅脑损伤伤情评价的比较

目的探讨简易运动评分(SMS)对颅脑损伤伤病情评价的可靠性。方法对72例颅脑损伤患者,分别行SMS和GCS评价并比较其伤情和不同伤情患者的预后。结果两种评价均为颅脑损伤轻型者57例,均为中重型者12例;有3例GCS评为中重型,而SMS评为轻型;SMS与GCS对伤情的评价无明显差异(P>0.05)。两种方法均评为重型者4例,3例恢复差(GOS1～3分),1例恢复良好(GOS4～5分);8例均为中型者,2例恢复差,6例良好;57例均为轻型者均恢复良好;3例GCS评为中型,而SMS评为轻型者均恢复良好。SMS与GCS分别评为颅脑损伤轻型或中型或轻型者中,预后无明显差异(P>0.05)。结论与GCS相比,SMS可作为脑损伤病情的评价方法之一,简便易行,结果可靠。     

Plasma glucose level in Nigerian Africans with head injury

Trauma is often associated with increased plasma glucose concentrations. This prospective study was designed to determine random plasma glucose concentrations in patients with head injury in our center and to determine if this is related to injury severity and outcome. Patients with head injury in whom the plasma glucose concentration could be determined at our accident and emergency unit during the study period were included. We obtained information on demographic data, diagnosis, injury severity using Glasgow Coma Scale scores, treatment with glucose-containing fluid prior to presentation in our center, plasma glucose on admission, 24 hours later and 72 hours later and outcome at discharge using the Glasgow Outcome Scale score. Hyperglycemia was defined as glucose concentrations above 11.1 mmol/L. Fifty eight patients were included in the study from October 2004 to December 2005. There were 46 males and 12 females (4:1). The mean age (± standard deviation [SD]) was 31.3 (16.4) years. Fourteen patients (24.1%) had mild head injury, 21 patients (36.2%) had moderate head injury and 23 patients (39.7%) had severe head injury. The outcome was good in 29 patients (50%), moderate disability in five patients (8.6%), severe disability in one (1.7%) and death in 10 (17.2%). Eighty percent of the patients who died had severe head injury. Most of the patients had a plasma glucose in the normal range irrespective of the severity of the head injury. Only one patient had a plasma glucose in the hyperglycemic range and that patient had a severe head injury. Fifty percent of the patients who died had a plasma glucose concentration in the normal range; none in the hyperglycemic range. This study shows that the plasma glucose is generally below hyperglycemic concentration in our patients irrespective of the severity of head injury.     

Prognostic implications of hyperglycaemia in paediatric head injury

Fifty children with head injury were evaluated in an attempt to estabilish a correlation between post-traumatic hyperglycaemia and long-term outcome. In all the patients, the blood glucose level was measured on admission and on the days following the trauma (threshold of normal value set at 150 mg/dl). Hyperglycaemia was seen more frequently in children with severe head injury than in those with mild and moderate head injury. It was present in 87.5% of the patients with a Glasgow Coma Score (GCS) ≤8 (the average blood glucose level on admission was 237.8±92 mg/dl), in 60% of the patients with a GCS of 9–12 (178±78.7 mg/dl) and only in 25% of those with a GCS of 13–15 (131.5±39 mg/dl). A close correlation was also seen between the outcome and the blood glucose level. In fact, the blood glucose on admission was higher in the patients with a poor outcome, i.e. in those having a Glasgow Outcome Score (GOS) of 2 or 3 and in those who died (GOS 1), than in the patients with a good outcome (GOS of 4 or 5). Finally, hyperglycaemia persisted beyond the first 24 h after trauma in all the children who died or who survived with a poor outcome. Hyperglycaemia, and especially its persistence over time, appears to be an important negative prognostic factor in children with head injury. Received: 14 May 1998     

Prognostic factors and outcome of children with severe head injury: an 8-year experience

OBJECTIVES: Our aim was to analyze prognostic factors and their association with outcome among children with severe head injury. METHODS: We conducted a retrospective study among children with severe head injury admitted to our Pediatric Intensive Care Unit (PICU) from November 1992 to December 2000. The patients were immediately evaluated for the severity of head injury (Glasgow Coma Score, GCS), clinical presentation, cerebral axial tomography, early complications (hypoxia and hypotension), metabolic and hematological alterations and early post-traumatic seizures. Six months after injury we applied the Glasgow Outcome Score (GOS). Correlations with GOS were evaluated using univariate and multivariate logistic models. RESULTS: In all, 122 children with severe head injury were identified. The patients presented the following scores: 18 (14.7.0%) children had a GOS of 1; 2 had a GOS of 2 (1.6%); 27 (22.2%) a GOS of 3 and 75 (61.5%) a GOS of 4 or 5. A low GOS was significantly and independently associated with low GCS, multiple trauma, the presence of hypoxia and hypotension, disseminated intravascular coagulation (DIC), hyperglycemia and early post-traumatic seizures. Hematological alterations (white blood cells) were also associated with a low GOS, though not significantly. CONCLUSION: In addition to GCS, types of trauma and brain lesion, hypoxia and hypotension, hemocoagulative disorders (DIC), hyperglycemia and early post-traumatic seizures are predictors of GOS. A knowledge of these prognostic factors and the correct management of children with severe head injury helps clinicians to improve outcome and to reduce morbidity and mortality.     

Motivation and Neuropsychological Test Performance Following Mild Head Injury

Effect of motivation on neuropsychological test performance in mild head injury was assessed. Motivation was measured using the Portland Digit Recognition Test. Three groups were compared: (a) mild head injury, financial incentives, good motivation; (b) mild head injury, financial incentives, poor motivation; (c) moderate/severe head injury, good motivation. The neuropsychological battery included measures of sensory function, motor function, attention, intelligence, reasoning, and memory. Mild head injury well motivated patients performed significantly better than the other two groups on some tests. Mild head injury poorly motivated individuals and moderate-severe head injury patients were indistinguishable on many tests. Consistent with previous reports, tactile sensory (finger recognition and Fingertip Number Writing Perception) and recognition memory (Rey Auditory Verbal Learning) tasks were identified as clinically useful measures of poor motivation. On these measures mild head injury well motivated examinees performed no better than moderate-severe patients, with both groups superior to mild head injury poorly motivated examinees. Sensitivity and specificity data are reported. Our measures of tactile sensation and verbal recognition memory were more affected by motivation than by the severity of head injury.     

经颅多普勒对外伤性脑血管痉挛的诊断价值

目的 探讨经颅多普勒(TCD)对外伤性脑血管痉挛的诊断价值及外伤性脑梗死的早期预防价值.方法 回顾性分析348例颅脑损伤病人的临床资料,均行TCD监测及CT检查.将TCD诊断为脑血管痉挛的病人按血管痉挛程度分为轻度、中度、重度组,并进行统计学分析.结果 TCD监测发现外伤性脑血管痉挛179例(51.44％),其中轻度组92例,中度组60例,重度组27例;其多在伤后2～3 d出现,持续5～7 d,10～14d后缓解.CT证实发生外伤性脑梗死24例,其中外伤性脑血管痉挛中度组4例,重度组20例;经统计学分析,脑血管痉挛严重程度与外伤性脑梗死的发生存在正相关(P＜0.01);经治疗1个月后GOS预后评分:恢复良好3例,轻度残疾8例,重度残疾7例,死亡6例.结论 TCD诊断外伤性脑血管痉挛安全、无创、有效,对早期预防外伤性脑梗死具有重要临床意义.     

Motivation and neuropsychological test performance following mild head injury

Effect of motivation on neuropsychological test performance in mild head injury was assessed. Motivation was measured using the Portland Digit RecognitionTest. Three groups were compared: (a) mildhead injury, financial incentives, good motivation; (b) mild head injury, financial incentives, poor motivation; (c) moderate/severe head injury, good motivation. The neuropsychological battery included measures of sensory function, motor function, attention, intelligence, abstract reasoning, and memory. Mild head injury well motivated patients performed significantly better than the other two groups on some tests. Mild head injury poorly motivated individuals and moderate-severe head injury patients were indistinguishable on many tests. Consistent with previous reports, tactile sensory (finger recognition and Fingertip Number Writing Perception) and recognition memory (Rey Auditory Verbal Learning) tasks were identified as clinically useful measures of poor motivation. On these measures mild head injury well motivated examinees performed no better than moderate-severe patients, with both groups superior to mild head injury poorly motivated examinees. Sensitivity and specificity data are reported. Our measures of tactile sensation and verbal recognition memory were more affected by motivation than by the severity of head injury.     

Prediction of outcome in mild to moderate head injury: a review

This paper reviews the functional outcome of patients sustaining mild and moderate head injury (HI). Discrepancies across studies in the definition of minor, mild, and moderate HI are discussed in terms of hindering the interpretation of recovery. The predictive value of acute severity indices, neuroimaging findings, and the results of other techniques are summarized. Measurement of outcome based solely on the Glasgow Outcome Scale (GOS) is critiqued, and it is recommended that a differentiated outcome scale involving emotional, behavioral, cognitive, and physical domains should be used.     

重型颅脑损伤合并高血糖术后短期胰岛素强化治疗的效果分析

目的 探讨重型颅脑损伤（TBI）合并高血糖标准大骨瓣减压术后胰岛素强化治疗的效果。方法 2018年1月至2019年12月收治重型TBI合并高血糖66例,均行标准大骨瓣减压术治疗。术后按照随机数字表法随机分为观察组（胰岛素强化治疗）和对照组（胰岛素常规治疗）,每组33例。两组均给予胰岛素持续静脉泵入治疗1周,观察组空腹血糖控制在3.9~6.1 mmol/L,对照组控制在8~10 mmol/L。比较分析两组治疗前及治疗后1周胰岛β细胞功能指标[胰岛素敏感指数（ISI）、胰岛素抵抗指数（HOMA-IR）]、血清炎性因子[C-反应蛋白（CRP）、白细胞介素-6（IL-6）、白细胞介素-8（IL-8）、肿瘤坏死因子-α（TNF-α）]以及并发症。结果 治疗1周,两组ISI、HOMA-IR以及血清CRP、IL-6、IL-8、TNF-α水平均较治疗前均明显改善（P<0.05）;而且,观察组明显优于对照组（P<0.05）。观察组感染发生率（21.21%,7/33）明显低于对照组（54.55%,18/33;P<0.05）。结论 对重型TBI高血糖,术后短期胰岛素强化治疗有利于胰岛功能恢复,减轻炎性反应,降低感染发生率