现代颅脑伤救治中的几个关键问题

颅脑外伤已成为青少年致死残的首要因素 ,每年还需花费大量的资金 ,给社会和家庭带来巨大的灾难。如何提高颅脑外伤的救治率、降低死残率已成为神经外科面临的重大课题。就近年有关颅脑外伤救治中的几个关键问题作一介绍 ,如院前急救和急救室处理、急性颅内高压与脑水肿的防治、创伤性蛛网膜下腔出血 (tSAH )与脑血管痉挛、长期昏迷的防治、低温与脑外伤、早期营养治疗等。     

Predictive Value of a New Brief Cognitive Test for Long-term Functional Outcome in Acute Traumatic Brain Injury

ObjectiveTo determine how results on the EXAmen Cognitif abrégé en Traumatologie (EXACT), a new test specifically designed to briefly assess global cognitive functioning during the acute phase of traumatic brain injury (TBI), can predict long-term functional outcome compared with length of posttraumatic amnesia (PTA), a well-established predictor.DesignInception cohort.SettingsLevel 1 trauma center.ParticipantsA total of 90 patients (N=90) hospitalized for a moderate or severe TBI.InterventionsNot applicable.Main Outcome MeasuresPerformance on the EXACT in the first 3 months after injury and results on the Disability Rating Scale (DRS) at follow-up 1-2 years later.ResultsEXACT scores were all correlated with length of PTA and DRS result. Compared with length of PTA, the EXACT added significantly to the regression and improved prediction of functional outcome. More specifically, a total score ≤80 on the EXACT was associated with a higher rate of long-term disability because of more severe TBI consequences. Behavioral regulation and executive functions were the cognitive domains that showed the most impairment, followed by attention and working memory as well as episodic memory. Except for length of PTA and hospital stay, the DRS score was not correlated with other demographic (age, education) or clinical variables (Glasgow Coma Scale and maximum score on the Therapy Intensity Level Scale).ConclusionsThe EXACT can be administered to most patients early in the acute phase of TBI, and results could be used, along with other predictors such as PTA, to estimate their long-term functional sequelae. The EXACT may be a promising brief cognitive instrument for future studies investigating recovery after TBI.     

创伤性脑损伤后认知障碍的海马氢质子磁共振波谱分析

目的:探讨海马氢质子磁共振波谱(1H-MRS)在创伤性脑损伤(TBI)后认知障碍的辅助诊断和评估中的价值.方法:选取轻度TBI后认知障碍患者(mi-TBI组)9例、中度TBI后认知障碍患者(mo-TBI组)19例,同时招募健康对照组10例,进行1H-MRS检查后分析三组双侧海马N-乙酰天门冬氨酸(NAA)、胆碱(Cho...     

Multiple Episodes of Mild Traumatic Brain Injury Result in Impaired Cognitive Performance in Mice

OBJECTIVES: Results from recent studies on animal models of concussion suggest that multiple, rather than single, episodes of mild traumatic brain injury result in impaired cognitive performance in mice. The objective of the present study was to administer multiple impacts to the heads of mice while directly measuring the force of the impacts to determine how these parameters are related to transient loss of consciousness, cognitive deficits, and potential neuropathologic effects. METHODS: even-week-old male C57BL/6 mice were randomly assigned to experimental conditions involving three impacts (weight-drop method) to the head to induce mild traumatic brain injury or to sham control procedures. Some impacted (n = 10) and sham control (n = 10) mice were evaluated behaviorally and tested for spatial learning using the Morris water maze (MWM), whereas other impacted (n = 10) and sham control (n = 5) mice were used for histopathologic analysis. RESULTS: The mean ( +/- SD) force of impact was 19 ( +/- 3.5) N. Impacted mice took longer to regain consciousness compared with sham control mice (p < 0.0005). Behavioral test results showed that the groups did not differ on activity or sensorimotor tests or during cued trials in the MWM. Impacted mice exhibited impaired spatial learning performance during place trials in the MWM (p < 0.05). Silver staining revealed a contra-coup type of injury involving ventral brain structures in contact with or in close proximity to the skull. CONCLUSIONS: This multiple-impact model, delivered within a specifiable force range, results in transient, reversible loss of consciousness, a contra-coup brain injury, and cognitive impairment.     

认知功能的药物康复

认知内容广泛丰富,记忆注意等均为认知的基础组成。脑损伤后如何促进认知功能的恢复就成为当今康复医学的主要课题。本文介绍了能促进记忆的常用药物,同时还介绍了增进注意功能的药物。     

Cognitive and Behavioral Impairment in Traumatic Brain Injury Related to Outcome and Return to Work

Benedictus MR, Spikman JM, van der Naalt J. Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.

Objective

To evaluate the cognitive and behavioral disturbances related to return to work (RTW) in patients with traumatic brain injury (TBI) with the application of a differentiated outcome scale.

Design

Longitudinal cohort study.

Setting

Level I trauma center.

Participants

Adults (N=434) with TBI of various severity.

Interventions

Not applicable.

Main Outcome Measures

Extended Glasgow Outcome Scale (GOS-E), Differentiated Outcome Scale (DOS), and RTW.

Results

Patients encountered problems in the physical (40%), cognitive (62%), behavioral (55%), and social domains (49%) of the DOS, with higher frequency related to severity of injury. Even those with mild TBI experienced cognitive (43%) and behavioral problems (33%). Patients with good recovery (58%) according to the GOS-E experienced problems in 1 or more domains of the DOS. Half the patients were able to resume previous vocational activities completely, although 1 in 3 experienced cognitive or behavioral problems. Using multivariate logistic regression analysis, the cognitive (odds ratio [OR], 10.548; confidence interval [CI], 5.99-18.67), behavioral (OR, 2.648; CI, 1.63-4.29), and physical domains (OR, 2.763; CI, 1.60-4.78) were significant (P<.01) predictors of RTW. For subcategories of TBI, the cognitive domain was predictive for RTW in those with moderate and severe TBI, whereas both the cognitive and behavioral domains were predictive for RTW in those with mild TBI.

Conclusions

With application of a more detailed outcome scale, cognitive and behavioral impairments interfering with RTW were present in a substantial part of patients with TBI in the chronic phase after injury. More research is needed exploring the cognitive and behavioral outcome in different categories of injury severity separately.     

重型颅脑损伤患者术后行高压氧辅助治疗的疗效观察

目的:评价重型颅脑损伤患者术后行高压氧辅助治疗效果。方法:对于入院时格拉斯哥评分(Glasgow coma scale,GCS)小于8分的228例颅内血肿患者均于24h内行颅内血肿清除术或同时行去骨瓣减压术。术后除常规治疗(108 例对照组)外,应用高压氧治疗(120例高压氧组,HBO组)。4周后进行GCS评分,6 个月进行格拉斯哥愈后评级(Glasgow outcomescale,GOS)。结果:两组治疗后4周的GCS评分,6个月的GOS评级有显著差异(P<0.01)。结论:应用高压氧辅助治疗,对于颅脑外伤术后患者的愈后康复有满意效果。     

Variation in Pediatric Traumatic Brain Injury Outcomes in the United States

Objective

To ascertain the degree of variation, by state of hospitalization, in outcomes associated with traumatic brain injury (TBI) in a pediatric population.

Design

A retrospective cohort study of pediatric patients admitted to a hospital with a TBI.

Setting

Hospitals from states in the United States that voluntarily participate in the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project.

Participants

Pediatric (age ≤19y) patients hospitalized for TBI (N=71,476) in the United States during 2001, 2004, 2007, and 2010.

Interventions

None.

Main Outcome Measures

Primary outcome was proportion of patients discharged to rehabilitation after an acute care hospitalization among alive discharges. The secondary outcome was inpatient mortality.

Results

The relative risk of discharge to inpatient rehabilitation varied by as much as 3-fold among the states, and the relative risk of inpatient mortality varied by as much as nearly 2-fold. In the United States, approximately 1981 patients could be discharged to inpatient rehabilitation care if the observed variation in outcomes was eliminated.

Conclusions

There was significant variation between states in both rehabilitation discharge and inpatient mortality after adjusting for variables known to affect each outcome. Future efforts should be focused on identifying the cause of this state-to-state variation, its relationship to patient outcome, and standardizing treatment across the United States.     

Persistent Pain in Adolescents Following Traumatic Brain Injury

Traumatic brain injury (TBI) is a leading cause of pediatric disability. Although persistent pain has been recognized as a significant postinjury complication, there is a paucity of data concerning the postinjury pain experience of youth. This study aimed to examine the prevalence of persistent pain in adolescents after TBI, identify risk factors for pain, and evaluate the impact of pain on adolescent health-related quality of life. Participants included 144 adolescents with mild to severe TBI who were followed over 36 months after injury. At 3-, 12-, 24-, and 36-month assessments, measures of pain intensity, depression, posttraumatic stress disorder, and health-related quality of life were completed by adolescents. Findings demonstrated that 24.3% of adolescents reported persistent pain (defined as usual pain intensity ≥3/10) at all assessment points after TBI. Female sex (odds ratio = 2.73, 95% confidence interval = 1.12–6.63) and higher levels of depressive symptoms at 3 months after injury (odds ratio = 1.26, 95% confidence interval = 1.12–1.43) were predictors of persistent pain at 36 months. Furthermore, mixed linear models indicated that early pain experience at 3 months following TBI was associated with a significantly poorer long-term health-related quality of life.