Functional outcome following rehabilitation in chronic severe traumatic brain injury patients: A prospective study

Objective:

The objective was to assess functional outcome of rehabilitation in chronic severe traumatic brain injury (TBI) in-patients.

Setting:

The study was performed at university tertiary research hospital.

Study Design:

A prospective cross-sectional study

Materials and Methods:

Forty patients (34 men) with mean age of 30.1 years (range 6--60, SD 10.8), severe TBI (Glasgow coma scale 3--8, duration of coma > 6 hours, post-traumatic amnesia> 1 day postinjury) were admitted in rehabilitation unit minimum 3 months (mean 7.7±4.6 months, range 3--22 months) following injury falling in Glasgow outcome scale (GOS) of 3. Functional recovery was assessed using the Barthel Index (BI) score and disability rating scores (DRS).

Data Analysis:

Paired Student''s t-test was used for the assessment of functional recovery using mean BI scores at admission and discharge. The Wilcoxon nonparametric test was used for the assessment of functional recovery by comparing admission and discharge DRS scores.

Results:

Mean duration of stay was 30.8 days (range 18--91, SD15.6). Significant functional recovery observed in patients comparing BI and DRS scores at admission and discharge (mean BI admission 50.5±25.4, range 0--85 vs. mean discharge BI score 61.1±25.3, range 0--95, P<0.001, mean DRS admission score 7.57±4.1, range 2.5--21.0 vs. mean discharge DRS score 6.36±4.3, range 1.0-21.0, P<0.001).

Conclusion:

Patients with severe TBI continue to show functional recovery even in chronic phase with rehabilitation. They are left with significant residual physical and cognitive deficits and would require long-term care and assistance from care givers for the daily activities, as suggested by the mean DRS score at discharge.     

Effect of methylphenidate on ICU and hospital length of stay in patients with severe and moderate traumatic brain injury

OBJECTIVE: Traumatic brain injury is one of the major causes of death and disability among young people. Methylphenidate, a neural stimulant and protective drug, which has been mainly used for childhood attention deficit/hyperactivity disorder, has shown some benefits in late psychosocial problems in patients with traumatic brain injury. Its effect on arousal and consciousness has been also revealed in the sub-acute phase of traumatic brain injury. We studied its effect on the acute phase of moderate and severe traumatic brain injury (TBI) in relation to the length of ICU and hospital admission. PATIENTS AND METHODS: Severely and moderately TBI patients (according to inclusion and exclusion criteria) were randomized to treatment and control groups. The treatment group received methylphenidate 0.3mg/kg per dose PO BID by the second day of admission until the time of discharge, and the control group received a placebo. Admission information and daily Glasgow Coma Scale (GCS) were recorded. Medical, surgical, and discharge plans for patients were determined by the attending physician, blinded to the study. RESULTS: Forty patients with severe TBI (GCS = 5-8) and 40 moderately TBI patients (GCS = 9-12) were randomly divided into treatment and control groups on the day of admission. In the severely TBI patients, both hospital and ICU length of stay, on average, were shorter in the treatment group compared with the control group. In the moderately TBI patients while ICU stay was shorter in the treatment group, there was no significant reduction of the period of hospitalization. CONCLUSION: There were no significant differences between the treatment and control groups in terms of age, sex, post resuscitation GCS, or brain CT scan findings, in either severely or moderately TBI patients. Methylphenidate was associated with reductions in ICU and hospital length of stay by 23% in severely TBI patients (P = 0.06 for ICU and P = 0.029 for hospital stay time). However, in the moderately TBI patients who received methylphenidate, there was 26% fall (P = 0.05) only in ICU length of stay.     

Blood mitochondrial enzymatic assay as a predictor of long-term outcome in severe traumatic brain injury

Recent studies have observed the central role of mitochondrial dysfunction in severe traumatic brain injury (sTBI). One hundred and seven sTBI patients (18–65 years old, presenting within 8 hours of injury) were randomised for a placebo controlled phase II trial of progesterone with or without hypothermia. We serially analysed blood mitochondrial enzymes (Complex I [C1], Complex IV [C4] and pyruvate dehydrogenase complex [PDH]) using a dipstick assay at admission and 7 days later for 37 patients, irrespective of assigned group. Favorable Glasgow Outcome Scale (GOS) at 1 year was associated with admission C1 levels above 0.19 μg, admission C4 levels above 0.19 μg and day 7 C1 levels above 0.17 μg, all per 25 μl of blood. Unfavorable GOS at 1 year was associated with admission serum PDH levels above 0.23 μg/25 μl of blood. Survivors at 1 year had significantly higher admission serum C1 levels above 0.19 μg/25 μl and day 7 C1 levels above 0.17 μg/25 μl. To our knowledge this is the first clinical trial associating blood mitochondrial enzymes with long-term outcome in sTBI. Serial monitoring and optimisation of blood C1, C4 and PDH levels could aid in prognostication and potentially guide in using mitochondrial targeted therapies. Blood mitochondrial enzymatic assay might suggest global reduction–oxidation status.     

Long-term neurological and neuropsychological outcome in patients with severe traumatic brain injury

Background

Severe traumatic brain injury (TBI) remains a major cause of death and disability worldwide. The aim of the study was to evaluate predictors for neurological and neuropsychological long-term outcome in patients with severe TBI treated according to an intracranial pressure (ICP-) targeted therapy.

Methods

From 08/2005 to 12/2008, 46 patients with severe TBI and more than 12 h of intensive care treatment were included in this study. Neurological outcome was assessed with the Glasgow Outcome Scale (GOS). Neuropsychological performance assessing 9 different domains was evaluated at long-term follow-up (median 20.5 months; range 10–46). Logistic regression was used to identify favourable outcomes according to the GOS and Fisher's exact tests were used to identify predictors of severe neuropsychological impairments at follow-up.

Results

Twenty-nine patients were available for neuropsychological assessment at long-term follow-up. Only 2 out of 29 patients presented normal or average neuropsychological findings throughout all 9 neuropsychological domains at long-term follow-up. The percentage of a favourable outcome (GOS 4-5) increased from 13.8% at hospital discharge to 75.8% at rehabilitation discharge to 79.3% at long-term follow-up, respectively. Age ≤40 was found to be a strong predictor of favourable outcome at follow-up (OR 5.95, 95% CI 1.41 25.00, p = 0.015). The GOS at hospital discharge was not a predictor for severe impairments in any of the 9 different neuropsychological domains (all p-values were p > 0.268). In contrast, the GOS at rehabilitation discharge was found to be a predictor of severe impairments at follow-up in all but one domain assessed (all p-values less than p < 0.038).

Conclusions

The GOS at rehabilitation discharge should be regarded as a better predictor for neuropsychological impairments at long-term follow-up than the GOS at hospital discharge. Even in patients with favourable GOS after finishing a course of rehabilitation, three quarters of these patients may have at least one severe neuropsychological deficit. Therefore, it remains of paramount importance to provide long-term neuropsychological support to further improve outcome after TBI.     

Functional outcome is tied to dynamic brain states after mild to moderate traumatic brain injury

The current study set out to investigate the dynamic functional connectome in relation to long‐term recovery after mild to moderate traumatic brain injury (TBI). Longitudinal resting‐state functional MRI data were collected (at 1 and 3 months postinjury) from a prospectively enrolled cohort consisting of 68 patients with TBI (92% mild TBI) and 20 healthy subjects. Patients underwent a neuropsychological assessment at 3 months postinjury. Outcome was measured using the Glasgow Outcome Scale Extended (GOS‐E) at 6 months postinjury. The 57 patients who completed the GOS‐E were classified as recovered completely (GOS‐E = 8; n = 37) or incompletely (GOS‐E < 8; n = 20). Neuropsychological test scores were similar for all groups. Patients with incomplete recovery spent less time in a segregated brain state compared to recovered patients during the second visit. Also, these patients moved less frequently from one meta‐state to another as compared to healthy controls and recovered patients. Furthermore, incomplete recovery was associated with disruptions in cyclic state transition patterns, called attractors, during both visits. This study demonstrates that poor long‐term functional recovery is associated with alterations in dynamics between brain networks, which becomes more marked as a function of time. These results could be related to psychological processes rather than injury‐effects, which is an interesting area for further work. Another natural progression of the current study is to examine whether these dynamic measures can be used to monitor treatment effects.     

老年人重型颅脑外伤预后分析(附73例报道)

目的分析老年重型颅脑外伤患者的临床资料，总结影响老年人重型颅脑外伤预后的因素。方法回顾性分析73例急性重型颅脑外伤老年患者的临床资料，比较生存组及死亡组中各种因素的构成比，确定其对预后的影响。统计方法使用t检验、X^2检验及Logistic回归分析。结果本组生存30例，其中恢复良好5例，轻中残9例，重残13例，植物生存3例；死亡43例，死亡率为58．9％。结论老年重型颅脑外伤（TBI）患者死亡率高，预后差。年龄是影响预后的独立因素；GCS评分、瞳孔对光反射、原发性昏迷时间等指标是判断预后的重要因素。     

高原地区重型颅脑损伤患者死亡因素分析

目的 分析高原地区的重型颅脑损伤患者的死亡率和死亡危险因素.方法 回顾性分析西藏军区总院2007年6月～2012年6月收治的367例高原地区重型颅脑损伤患者的病例资料,应用多因素logistic回归分析确定引起死亡的危险因素.结果 患者入院3个月的总死亡率为22％(80/367).患者受伤至入院时间(OR=1.805),入院时GCS评分(OR =1.991)、孔对光反射情况(OR =2.033)和头颅CT显示的中线移位程度(OR =1.717)为死亡的独立危险因素.患者性别、年龄和居住地海拔高度对于死亡率的影响未显示出统计学意义.结论 本研究分析了高原地区重型颅脑损伤死亡的危险因素.受伤至入院时间较长、入院GCS评分低、双侧瞳孔散大或CT显示中线移位＞10 mm的重型颅脑损伤患者死亡率高.这些发现有利于制定临床治疗方案,改善患者预后.     

镇静镇痛对重型颅脑损伤患者术后颅内压的影响分析

目的探讨镇静镇痛对重型、特重型颅脑损伤（TBI）患者术后颅内压（ICP）的影响。 方法选取湖州市第一人民医院神经外科自2016年1月至2018年6月收治的重型TBI患者45例,根据GCS评分将患者分为重型TBI组（GCS评分6~8分,26例）与特重型TBI组（GCS评分3~5分,19例）,观察2组镇静镇痛下及撤除镇静镇痛/唤醒下ICP值波动情况。 结果特重型TBI患者在镇静镇痛前后ICP差异无统计学意义（P>0.05）,重型TBI患者撤除镇静镇痛/唤醒后,ICP前后变化差异有统计学意义（P<0.05）。 结论镇痛镇静与重型TBI开颅术后颅内压力波动有显著相关性,使用镇静镇痛可获得安全、平稳的ICP。     

脑创伤长期意识障碍患者脑干反射表现与清醒结果的关系

目的 探讨脑创伤(TBI)长期意识障碍患者脑干反射(BSR)表现与清醒预后的关系.方法 记录自2010年3月至2011年6月南方医科大学珠江医院神经外科收治的60例重型TBI后意识障碍超过2周患者的BSR表现.以TBI后6个月患者是否清醒为标准,分为清醒组与未清醒组,两组间运用独立样本x2检验筛选出有意义的指标. 结果 60例重型TBI患者6个月内清醒36例,清醒率为60.0％.BSR的异常概率为23.8％,BSR中左侧睫脊反射,左侧垂直性眼前庭反射,双侧瞳孔对光反射以及双侧眼心反射出现阴性的表现在清醒与未清醒组间差异差异有统计学意义(P＜0.05),上述BSR异常时患者的未清醒率较高. 结论 BSR的表现可客观、准确地反映TBI长期意识障碍患者的脑损伤程度并对患者的清醒结果进行预测.     

阶梯减压下去骨瓣减压术对重度颅脑损伤患者术后转归的影响

目的探讨阶梯减压下去骨瓣减压术对重度颅脑损伤（sTBI）患者术后转归的影响。 方法将吉林大学第一医院二部神经外科自2014年11月至2015年12月收治的行去骨瓣减压术的sTBI患者68例采用随机数字表法分为观察组和对照组各34例。观察组术中全程监测颅内压,采用阶梯减压的方法;对照组行标准外伤大骨瓣减压术。术后1个月采用Baethel指数（BI）评估日常生活能力,采用肢体运动功能运动量表（FM）评估肢体运动功能,比较手术并发症发生率,术后6个月采用GOS评分评估患者近期预后。 结果观察组的恢复良好率（41.18%）明显高于对照组（17.64%）,差异具有统计学意义（P<0.05）;观察组术后1个月BI评分、FM评分（78.37±8.96、83.67±14.72）高于对照组（65.24±7.91、72.33±13.68）,差异具有统计学意义（P<0.05）;观察组急性脑膨出发生率（5.89%）低于对照组（23.53%）,差异具有统计学意义（P<0.05）;术后迟发性颅内血肿、大面积脑梗的几率（8.82%、5.89%）略低于对照组（26.47%、11.76%）,差异无统计学意义（P>0.05）。 结论阶梯减压下去骨瓣减压术可降低sTBI患者急性脑膨出发生率,改善近期预后。     

控制性减压在重型颅脑损伤手术中的应用

目的 探讨控制性减压术治疗重型颅脑损伤的临床疗效。方法 2014年1月至2017年3月共收治符合标准的颅脑损伤146例,采用控制性减压术治疗52例（观察组）,标准大骨瓣减压术治疗94例（对照组）。结果 观察组术后1周病死率（17.3%）与对照组（20.2%）无统计学差异（P>0.05）。观察组术中出现急性脑膨出发生率（13.5%）明显低于对照组（28.7%;P<0.05）。观察组术后迟发性颅内血肿发生率（14.3%）、脑积水发生率（11.9%）均明显低于对照组（分别为36.8%、30.3%;P<0.05）。伤后6个月按GOS评分评估疗效。观察组恢复良好27例,中残6例,重残3例,植物生存2例,死亡14例;对照组恢复良好30例,中残6例,重残15例,植物生存14例,死亡29例。观察组恢复良好率（51.9%）明显高于对照组（31.9%;P<0.05）。结论 重型、颅脑损伤去骨板减压术中采用控制性减压方法有助于减少手术并发症,改善病人预后。     

重型颅脑损伤术中急性脑膨出应对措施

目的探讨重型颅脑损伤手术中急性脑膨出的机理与处理措施。方法回顾性分析58例在颅脑手术过程中发生脑膨出的重型颅脑损伤患者临床资料,影像学资料及应对措施,采用标准大骨瓣减压、过度通气、咬除颅底骨质、阶梯性减压、及时复查颅脑CT等综合措施。结果术后随访三月按GOS评定预后恢复良好19例、轻残11例、重残11例、植物生存5例、死亡12例。迟发性血肿(63.8%),弥漫性脑肿胀(27.6%)及脑梗死(8.6%)是重型颅脑损伤手术中急性脑膨出的主要原因。结论对重型颅脑损伤手术中急性脑膨出的患者要正确判断,区别原因采取相应的措施。     

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.     

创伤性闭合性中型颅脑损伤动物模型的建立

目的构建一种创伤性闭合性中型颅脑损伤（TBI）动物模型。 方法雄性SD大鼠80只,完全随机平均分为4组,每组20只,包括3组不同程度的TBI（A、B、C）组和假手术（N）组。参照Marmarou损伤模型,A、B、C组分别按拟定的打击高度（1.0、1.5、2.0 m）使重量为450 g的钢棒自由下落撞击大鼠头部建立TBI。观察各组大鼠伤后一般状况、神经行为学、脑组织形态学等改变。 结果伤后14 d内,N、A、B、C组死亡率分别为0%、5%、20%、60%,随着致伤量的增加,死亡率增加（P<0.05）,伤后各观察时间点神经功能缺损评分（mNSS）升高（P<0.05）,均高于N组,差异均具有统计学意义。HE染色结果提示,与N组比较,随着致伤量的增加,光镜下可见基质疏松、神经元细胞周围间隙和血管间隙增宽、神经元细胞排列紊乱且变性、神经胶质肿胀变性程度更加明显。免疫组织化学染色结果提示,与N组比较,A、B、C组大脑皮质β-APP、NF-L阳性表达程度增强。 结论以450 g的钢棒自1.5 m高处自由打击大鼠颅骨可成功建立创伤性闭合性中型颅脑损伤动物模型,其病理学特征明显,重复性和稳定性好。     

亚低温对重型颅脑创伤合并急性创伤性凝血病影响的临床研究

目的 研究亚低温对重型颅脑创伤(sTBI)合并急性创伤性凝血病(ATC)患者的影响及其临床意义.方法 83例sTBI合并AT℃患者随机分为亚低温治疗组42例、常规治疗组(对照组)41例.亚低温治疗组均于伤后24h内接受亚低温治疗.分别测量两组患者不同时间点的凝血酶原时间(PT)、部分凝血酶原时间(APTT)、凝血时间(TT)、纤维蛋白原(FIB)及D-二聚体水平,同时监测患者颅内压(ICP)以及生命体征、血气、血电解质及动脉血氧饱和度等,并根据GOS评估法判断预后.结果 亚低温治疗组患者PT、APTT、TT、FIB及D-二聚体与对照组相比差异无统计学意义(P＞0.05),而颅内压明显降低(P＜0.01);生命体征、血气、血电解质、动脉血氧饱和度差异无统计学意义,无严重并发症,病死率低,预后改善明显.结论 亚低温治疗不会增加sTBI合并ATC患者出现凝血障碍及纤溶亢进的风险,并且能有效地降低颅内压,具有肯定的脑保护作用,是一项安全有效的治疗措施.     

过渡期护理模式对重度颅脑损伤患者的作用

目的探讨过渡期护理模式对于重度颅脑损伤患者的临床价值。方法选择172例重度颅脑损伤患者为研究对象,均经重症监护室(ICU)治疗后转入普通病房。随机均分为过渡期护理组86例和对照组86例。1周后对比2组不良事件发生率、焦虑抑郁状况以及平均出院时间、家属满意率。结果过渡期护理组不良事件发生率低于对照组,差异统计学意义(3.5%vs 16.3%,χ~2=7.898,P0.05);焦虑与抑郁发生率低于对照组,差异有统计学意义(4.7%vs 15.1%,χ~2=5.287,P0.05);平均住院时间比对照组短,差异有统计学意义(24.1±6.3vs 32.4±5.7,t=-9.060,P0.05);患者家属满意率高于对照组,差异有统计学意义(94.2%vs 80.2%,χ~2=7.505,P0.05)。结论实施过渡期护理模式可以改善重度颅脑损伤患者的心理状态,利于疾病的恢复,值得推广应用。     

重型颅脑损伤术后发生脑积水的危险因素分析

目的探讨重型颅脑损伤患者术后脑积水发生的危险因素。方法回顾性分析手术后276例重型颅脑损伤手术患者的临床资料。随访6个月后根据脑积水诊断标准,分为脑积水组(47例)和非脑积水组(229例),采用单因素分析和逐步Logistic回归分析,比较两组患者颅内脑挫裂伤、脑室出血、硬膜下血肿、硬膜外血肿、颅骨损伤、颅骨线型骨折、脑脊液蛋白水平及压力等因素。结果随访结果显示,重型颅脑损伤患者术后脑积水发生率为17.03%(47/276);单因素分析结果显示脑积水组和非脑积水组在年龄、脑室出血、硬膜下血肿、昏迷(有无、持续时间)、格拉斯哥昏迷评分(Glasgow Coma Scale,GCS)、去骨瓣减压术、创伤性蛛网膜下腔出血(traumatic subarachnoid hemorrhage,tSAH)、加尔维斯顿定位和失忆测试(Galveston Orientation and Amnesia Test,PTA)、功能独立性测评(Function Independent Measure,FIM)的差异均有统计学意义(P0.05);Logistic回归结果显示高龄、硬膜下血肿、昏迷时间长、GCS低分值,去骨瓣减压术与重型颅脑创伤后的脑积水的发生显著正相关。结论高龄、有硬膜下血肿、GCS评分低、接受去骨瓣减压术是重型颅脑创伤后脑积水的危险因素。     

重型颅脑损伤开颅术中急性脑膨出的防治

目的 探讨重型颅脑损伤患者开颅术中急性脑膨出的原因及防治措施.方法 回顾性分析43例术中出现急性脑膨出的重型颅脑损伤患者的临床资料.结果 本组病人术中急性脑膨出的原因包括迟发性颅内血肿21例,弥漫性脑肿胀13例,长时间脑疝(2 h以上)4例,外伤性大面积脑梗死3例,术中低血压或低氧血症2例.出院后半年按GOS评定预后:恢复良好14例,重、中残6例,植物生存3例,死亡20例.结论 术前详细了解受伤机制,认真研究影像学资料对术中脑膨出的预判具有重要意义;针对不同病因的综合治疗有助于改善患者预后及降低患者死亡率.     

Working memory brain activation following severe traumatic brain injury

Functional magnetic resonance imaging (fMRI) has shown that brain activation during performance of working memory (WM) tasks under high memory loads is altered in adults with severe traumatic brain injury (TBI) relative to uninjured subjects (Perlstein et al., 2004; Scheibel et al., 2003). Our study attempted to equate TBI patients and orthopedically injured (OI) subjects on performance of an N-Back task that used faces as stimuli. To minimize confusion in TBI patients that was revealed in pilot work, we presented the memory conditions in two separate tasks, 0- versus 1-back and 0- versus 2-back. In the 0- versus 1-back task, OI subjects activated bilateral frontal areas more extensively than TBI patients, and TBI patients activated posterior regions more extensively than OI subjects. In the 0- versus 2-back task, there were no significant differences between the groups. Analysis of changes in activation over time on 1-back disclosed that OI subjects had decreases in bilateral anterior and posterior regions, while TBI patients showed activation increases in those and other areas over time. In the 2-back condition, both groups showed decreases over time in fusiform and parahippocampal gyri, although the OI group also showed increases over time in frontal, parietal, and temporal areas not seen in the TBI patients. The greatest group differences were found in the 1-back condition, which places low demand on WM. Although the extent of activation in the 2-back condition did not differ between the two groups, deactivation in the 2-back condition was seen in the OI patients only, and both groups' patterns of activation over time varied, suggesting a dissociation between the TBI and OI patients in recruitment of neural areas mediating WM.     

术中颅内压监测在治疗重型颅脑创伤中的应用

目的 探讨术中持续颅内压(ICP)监测在治疗重型颅脑创伤患者中的应用价值.方法 对我科2008年3月至2010年3月收治的58例重型颅脑创伤患者的术中ICP监测结果进行分析.根据预后情况分为较好组(GOS 4 ～5分)和较差组(GOS1 ～3分),分析并比较两组患者开颅术中ICP的波动规律及其对手术操作和预后的影响.结果 两组间手术初始、去除骨瓣后及关颅术后的ICP均值以及两组各步骤间ICP波动变化差异有统计学意义(P＜0.01).结论 术中ICP监测在治疗重型颅脑外伤患者中有助于及时发现问题,指导治疗及评估预后,具有重要的临床应用价值.