慢性意识障碍患者阵发性交感神经过度兴奋综合征的临床分析

目的探讨慢性意识障碍患者阵发性交感神经过度兴奋综合征(PSH)的发生率、与意识障碍严重程度的关系以及对意识的影响。方法回顾性分析126例慢性意识障碍患者的临床资料,根据临床特征分为PSH组和对照组,发病后1年进行格拉斯哥结局量表(GOS)评分。比较两组患者性别、年龄、损伤机制、格拉斯哥昏迷量表(GCS)评分、修改版昏迷恢复量表(CRS-R)评分、脑电图结果(按照Synek标准分级)、重症监护时间(ICU时间)和GOS评分的差异。结果慢性意识障碍患者PSH的发生率为26.19%(33/126)。在随访成功的83例患者中,PSH组26例,对照组57例;PSH组患者年龄(35.19±13.11)岁较对照组(42.86±16.17)岁年轻、GOS评分(1.88±0.99)分较对照组(2.53±1.36)分低、意识恢复的患者(6例,23.08%)较对照组(28例,49.12%)少,差异有统计学意义(P0.05);两组患者在性别、损伤机制、GCS评分、CRS-R评分、脑电图分级和ICU时间方面的差异无统计学意义(P0.05)。结论 PSH是慢性意识障碍患者的常见并发症,其发病年龄相对年轻,PSH的出现会阻碍患者意识恢复。     

金刚烷胺对颅脑损伤患者意识障碍的临床疗效

目的 探讨金刚烷胺对颅脑损伤后意识障碍的疗效。方法 2012年7月至2014年7月收治颅脑损伤伴意识障碍52例,根据治疗方法分为观察组（25例）和对照组（27例）。对照组采取常规的对症支持及康复治疗;观察组在对照组治疗的基础上,每日给予金刚烷胺（100mg/次,2次/d）,连续4周。比较两组治疗前后残疾评定量表（DRS）评分及修订版昏迷恢复量表（CRS-R）评分。结果 两组患者治疗后DRS评分及CRS-R评分较治疗前均明显改善（P<0.05）,而且观察组改善更明显（P<0.05）。用药过程中,对照组有5例出现恶心呕吐等胃肠道反应,观察组有6例;对照组有2例出现癫痫发作,观察组有1例,经对症治疗后均能耐受药物。结论 金刚烷胺对颅脑损伤的意识障碍具有一定的促醒作用,有一定的临床疗效。     

既定训练动作的广场舞对帕金森患者认知功能障碍的疗效观察

目的 研究既定动作的广场舞训练对轻至中度帕金森患者认知功能障碍的疗效。方法 收集80例轻至中度帕金森患者,依照随机分配原则分为治疗组和对照组,各40例。两组患者均接受常规治疗,并且每半个月提供一次时间为1 h的非运动性健康教育课程。治疗组患者学习特定动作,按规定时间进行训练;对照组密切观察病情变化。干预前后均应用简易精神状态检查量表（MMSE）和蒙特利尔认知评估量表（MoCA）对两组患者认知状况进行评分。结果 干预6个月后,治疗组患者MoCA得分（23.23±2.17）、MMSE得分（23.25±2.34）分别高于干预前（19.93±2.97）,（19.95±3.19）,差异有统计学意义（P<0.05）;且治疗组MoCA得分、MMSE得分高于对照组,差异有统计学意义（P<0.05）。结论 既定动作的广场舞训练对改善帕金森患者认知功能障碍有效。     

由缺血缺氧性脑病导致的意识障碍患者意识恢复的相关因素分析

目的 探讨由缺血缺氧性脑病导致的意识障碍患者的临床特点及影响意识康复的相关因素。方法 回顾性分析2013年10月至2018年10月在南部战区总医院神经康复一科住院的46例由缺血缺氧性脑病导致慢性意识障碍患者的临床资料,采用二元logistic回归方法对可能影响意识恢复的相关因素进行分析。结果 单因素分析显示植物状态持续时间（P<0.001）、发病至神经康复时间（P=0.001）、（CRS-R）评分（P=0.016）、性别（P=0.034）、阵发性交感神经过度兴奋（P=0.016）、体感诱发电位（P=0.002）和脑电图（P=0.003）与意识恢复相关,差异具有统计学意义（P<0.05）。logistic回归分析显示,植物状态持续时间（OR=1.077,95%CI：1.009~1.148,P=0.025）、阵发性交感神经过度兴奋（OR=15.511,95%CI：1.210~198.833,P=0.035）是意识恢复的独立影响因素。结论 植物状态持续时间过长、阵发性交感神经过度兴奋的出现是影响缺血缺氧性脑病慢性意识障碍患者意识恢复的临床指标。     

阵发性交感神经过度兴奋对重症卒中患者预后的影响

目的 回顾性分析阵发性交感神经过度兴奋（PSH）对重症卒中患者的意识水平、功能预 后以及并发症的影响。方法 收集 2018 年 1 月至 2019 年 1 月由外院神经重症监护室转入首都医科大学 附属复兴医院康复中心行康复治疗的重症卒中患者 36 例,比较合并 PSH 组（11 例）及非 PSH 组（25 例）之 间入院时和出院时的基线信息,比较两组修订版昏迷恢复量表评分（CRS-R）、功能独立性评分（FIM）和 格拉斯哥预后评分（GOS）,以及住院期间并发症的发生率。结果 PSH 组患者更年轻［（43.60±7.21）岁 比（63.25±16.13）岁,P=0.023］。两组之间在入院时和出院时 CRS-R 评分、FIM 评分和 GOS 评分差异无 统计学意义（P＞ 0.05）。并发症方面,脑积水、胃肠道疾病和健侧张力异常升高发生率在两组之间差异 有统计学意义,在 PSH 组发生率更高（分别为 6/11 比 12.00%,P=0.021;8/11 比 20.00%,P=0.034;5/11 比 4.00%,P=0.006）。结论 本研究发现 PSH 发作对重症卒中患者的意识水平和功能预后没有明显负性影 响,合并 PSH 的重症卒中患者更容易出现脑积水、消化道疾病及健侧的异常张力升高。但本研究样本 量较小,混杂因素偏多,还需进一步扩大样本量进行随访观察。     

改良大骨瓣减压术对颅脑损伤患者神经功能及远期预后的影响

目的 探讨改良大骨瓣减压术对颅脑损伤神经功能及预后的影响。方法 2010年8月至2013年6月行大骨瓣减压术治疗颅脑损伤86例,实施改良大骨瓣减压术43例（观察组）,实施传统大骨瓣减压术43例（对照组）,所有患者术后随访2年。结果 两组患者治疗前美国国立卫生研究院卒中量表（NIHSS）评分、GCS评分无明显差异（P>0.05）,治疗后NIHSS评分均显著降低（P<0.05）,GCS评分均显著升高（P<0.05）,观察组改善更明显（P<0.05）;观察组不良预后率、并发症发生率分别为39.53%、9.30%,均显著低于对照组（分别为69.77%、27.91%;P<0.05）。观察组手术时间与术中出血量显著高于对照组（P<0.05）。结论 改良大骨瓣减压术可显著改善颅脑损伤患者的神经功能和预后。     

慢性意识障碍并发阵发性交感神经过度兴奋综合征的危险因素及其对预后的影响

目的观察慢性意识障碍患者阵发性交感神经过度兴奋综合征(PSH)的发生率,探讨PSH发生的危险因素及其对预后的影响。方法回顾性分析2010年1月至2016年12月收治的142例慢性意识障碍患者的临床资料。记录其性别、年龄、损伤机制、修改版昏迷恢复量表(CRS-R)评分、重症监护(ICU)时间、头颅影像损伤位置,是否行脑部手术,有无脑积水、癫痫、感染、高血压、糖尿病。结果慢性意识障碍患者PSH的发生率为28.87%(41/142)。PSH组患者的年龄比无PSH组小,CRS-R评分比无PSH组低,脑室周围损伤患者和脑积水患者的比例比无PSH组高,糖尿病患者的比例比无PSH组低,差异均有统计学意义(均P0.05)。意识恢复组PSH患者的比例比意识未恢复组低,CRS-R评分比意识未恢复组高,ICU住院时间比意识未恢复组短,脑积水患者的比例比意识未恢复组低,差异均有统计学意义(均P0.05)。Logistic回归分析结果显示,年龄、CRS-R评分和脑室周围损伤是慢性意识障碍患者发生PSH的独立影响因素;PSH、CRS-R评分、ICU时间和脑积水是慢性意识障碍患者意识恢复的独立影响因素。结论 PSH是慢性意识障碍患者的常见并发症,年轻患者或脑室周围损伤患者容易发生。PSH将阻碍患者意识恢复。     

两种微创手术方法治疗基底节区中度脑出血临床疗效的比较研究

目的 比较研究CT实时引导下软通道穿刺手术和小骨窗微创开颅手术治疗基底节区脑出血。方法 选取266例出血量在20~40毫升的基底节区脑出血患者,其中208例采用CT实时引导下软通道穿刺血肿腔手术（穿刺组）,58例患者行微创开颅手术（开颅组）。两组病人从住院天数、水肿期意识加深情况、再出血率及预后等方面进行比较。结果 两组在平均住院天数（穿刺组11.53±0.418天VS开颅组11.30±0.778天）、入院3天GSC评分下降（穿刺组1.53±0.160分VS手术组1.48±0.232分）及再出血率（穿刺组1.92% VS开颅组1.72%）方面均无统计学差异（P>0.05）;而在出院时NIHSS评分提高方面,穿刺组较开颅组提高更显著（穿刺组2.98±0.247分VS开颅组2.05±0.186分,P<0.05）。结论 对于基底节区中度脑出血患者,血肿腔穿刺手术和微创开颅手术比较,前者预后改善较后者明显。     

依达拉奉联合丙泊酚治疗急性脑梗死的疗效观察

目的 观察依达拉奉联合丙泊酚治疗急性脑梗死的临床疗效。方法 118例急性脑梗死患者随机分为依达拉奉常规治疗组（对照组） 和依达拉奉联合丙泊酚治疗组（观察组）。治疗后第14天采用欧洲卒中量表（ESS）评分和日常生活活动能力（ADL）评分评估疗效。结果 两组患者治疗前ESS评分和ADL评分无统计学差异（P>0.05）;治疗后第14天两组患者ESS评分和ADL评分较治疗前均有改善（P<0.05）,观察组较对照组有显著性差异（P<0.05）。结论 依达拉奉联合丙泊酚治疗急性脑梗死能有效改善神经功能缺损,提高临床疗效。     

修改版昏迷恢复量表对意识障碍患者预后的评估价值

目的探讨修改版昏迷恢复量表(CRS-R)对意识障碍患者预后的评估价值。方法对29例重症脑部病变意识障碍患者进行CRS-R评分,根据评分分为植物状态(VS)和最小意识状态(MCS)。在患者出院≥3个月后进行格拉斯哥结局量表(GOS)评分;并对两个量表评分的相关性进行分析。结果本组VS患者20例、MCS患者9例,二者CRS-R评分分别为(5.15±2.35)分和(11.88±4.01)分。VS患者GOS评分≤3分(预后差)的比率(95%,19/20)显著高于MCS患者(44.4%,4/9)(P0.05)。Pearson相关分析显示,CRS-R评分与GOS评分呈正相关(r=0.558,P0.05)。CRS-R评分的子项中,运动、言语和交流与GOS评分呈正相关(r=0.663,r=0.637,r=0.424,均P0.05);而听觉、视觉和唤醒度与GOS评分无关。结论意识障碍患者CRS-R评分越高,预后越好。     

Glasgow Coma Scale on admission is correlated with postoperative Glasgow Outcome Scale in chronic subdural hematoma

OBJECTIVE: To evaluate the correlation between admission Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) in chronic subdural hematoma (CSDH). METHODS: 128 consecutive patients (107 men and 21 women) with CSDH were studied and the correlation between GCS on admission and postoperative GOS was determined. RESULTS: GCS and GOS were correlated with a Spearman rank correlation coefficient of 0.557 (p<0.01). CONCLUSION: GCS and GOS are well-correlated in CSDH.     

The importance of polysomnography in the evaluation of prolonged disorders of consciousness: sleep recordings more adequately correlate than stimulus-related evoked potentials with patients’ clinical status

ObjectivesThe aim of our study was to evaluate the importance of sleep recordings and stimulus-related evoked potentials (EPs) in patients with prolonged disorders of consciousness (DOCs) by correlating neurophysiologic variables with clinical evaluation obtained using specific standardized scales.MethodsThere were 27 vegetative state (VS) and 5 minimally conscious state (MCS) patients who were evaluated from a clinical and neurophysiologic perspective. Clinical evaluation included the Coma Recovery Scale-Revised (CRS-R), Disability Rating Scale (DRS), and Glasgow Coma Scale (GCS). Neurophysiologic evaluation included 24-h polysomnography (PSG), somatosensory EPs (SEPs), brainstem auditory EPs (BAEPs), and visual EPs (VEPs).ResultsPatients with preservation of each single sleep element (sleep–wake cycle, sleep spindles, K-complexes, and rapid eye movement [REM] sleep) always showed better clinical scores compared to those who did not have preservation. Statistical significance was only achieved for REM sleep. In 7 patients PSG showed the presence of all considered sleep elements, and they had a CRS-R score of 8.29 ± 1.38. In contrast, 25 patients who lacked one or more of the sleep elements had a CRS-R score of 4.84 ± 1.46 (P < .05). Our multivariate analysis clarified that concurrent presence of sleep spindles and REM sleep were associated with a much higher CRS-R score (positive interaction, P < .0001). On the other hand, no significant associations were found between EPs and CRS-R scores.ConclusionsPSG recordings have proved to be a reliable tool in the neurophysiologic assessment of patients with prolonged DOCs, correlating more adequately than EPs with the clinical evaluation and the level of consciousness. The main contribution to higher clinical scores was determined by the concomitant presence of REM sleep and sleep spindles. PSG recordings may be considered inexpensive, noninvasive, and easy-to-perform examinations to provide supplementary information in patients with prolonged DOCs.     

The FOUR Score Predicts Mortality,Endotracheal Intubation and ICU Length of Stay After Traumatic Brain Injury

Background

The Glasgow Coma Scale (GCS) is the most widely accepted scale for assessing levels of consciousness, clinical status, as well as prognosis of traumatic brain injury (TBI) patients. The Full Outline of UnResponsiveness (FOUR) score is a new coma scale developed addressing the limitations of the GCS. The aim of this prospective cohort study was to compare the performance of the FOUR score vs. the GCS in predicting TBI outcomes.

Methods

From April to July 2011, 60 consecutive adult patients with TBI admitted to the Alexandria Main University Hospital intensive care units (ICU) were enrolled in the study. GCS and FOUR score were documented on arrival to emergency room. Outcomes were in-hospital mortality, unfavorable outcome [Glasgow outcome scale extended (GOSE) 1–4], endotracheal intubation, and ICU length of stay (LOS).

Results

Fifteen (25 %) patients died and 35 (58 %) had unfavorable outcome. When predicting mortality, the FOUR score showed significantly higher area under receiver operating characteristic curve (AUC) than the GCS score (0.850 vs. 0.796, p = 0.025). The FOUR score and the GCS score were not different in predicting unfavorable outcome (AUC 0.813 vs. 0.779, p = 0.136) and endotracheal intubation (AUC 0.961 vs. 0.982, p = 0.06). Both scores were good predictors of ICU LOS (r ² = 0.40 [FOUR score] vs. 0.41 [GCS score]).

Conclusions

The FOUR score was superior to the GCS in predicting in-hospital mortality in TBI patients. There was no difference between both scores in predicting unfavorable outcome, endotracheal intubation, and ICU LOS.     

高血糖-弥漫性轴索损伤患者神经损伤严重度和预后的指示剂

目的研究外伤性弥漫性轴索损伤患者高血糖与预后的关系。方法前瞻性对 118例中、重型外伤性弥漫性轴索损伤患者进行研究, 监测入院时、入院后 3 d、7 d 和两周时的神经元特异性烯醇化酶(NSE)、血糖、GCS, 于出院时和三个月后作 GOS 预后评分, 分析血糖水平与损伤严重度和神经功能预后的关系。结果死亡患者入院时血糖水平显著高于存活患者 (260mg/dLvs 130 mg/dL,P<0.005)。入院时血糖≥260 mg/dL 的患者均死亡。结论弥漫性轴索损伤常发生应激反应性早期高血糖, 它是损伤严重度的指示剂和可靠的预后预测指标。     

Hyperbaric oxygen therapy for the treatment of traumatic brain injury: a meta-analysis

Compelling evidence suggests the advantage of hyperbaric oxygen therapy (HBOT) in traumatic brain injury. The present meta-analysis evaluated the outcomes of HBOT in patients with traumatic brain injury (TBI). Prospective studies comparing hyperbaric oxygen therapy vs. control in patients with mild (GCS 13–15) to severe (GCS 3–8) TBI were hand-searched from medical databases using the terms “hyperbaric oxygen therapy, traumatic brain injury, and post-concussion syndrome”. Glasgow coma scale (GCS) was the primary outcome, while Glasgow outcome score (GOS), overall mortality, and changes in post-traumatic stress disorder (PTSD) score, constituted the secondary outcomes. The results of eight studies (average age of patients, 23–41 years) reveal a higher post-treatment GCS score in the HBOT group (pooled difference in means = 3.13, 95 % CI 2.34–3.92, P < 0.001), in addition to greater improvement in GOS and lower mortality, as compared to the control group. However, no significant change in the PTSD score was observed. Patients undergoing hyperbaric therapy achieved significant improvement in the GCS and GOS with a lower overall mortality, suggesting its utility as a standard intensive care regimen in traumatic brain 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     

Glasgow昏迷量表在高血压性脑出血急救策略选择中的作用

目的探讨入院时Glasgow昏迷量表(GCS)评分对高血压性脑出血患者急救策略的影响。方法共286例高血压性脑出血患者中186例接受手术治疗,包括GCS评分5~8分94例、9~11分71例和12~14分21例,分别予血肿清除术联合去骨瓣减压术(63例,22.03%)、单纯血肿清除术(21例,7.34%)和血肿钻孔引流术或脑室外引流术(102例,35.66%);100例接受保守治疗,包括GCS评分5~8分25例、9~11分27例、12~14分25例和15分23例。随访3~6个月,采用Glasgow预后分级(GOS)评价疗效。结果 GCS评分5~8分组失访6例(5.04%),GOS分级1级14例(11.76%)、2级21例(17.65%)、3级39例(32.77%)、4级22例(18.49%)、5级17例(14.29%);GCS评分9~11分组失访2例(2.04%),GOS分级1级6例(6.12%)、2级2例(2.04%)、3级6例(6.12%)、4级48例(48.98%)、5级34例(34.69%);GCS评分12~14组GOS分级4级15例(32.61%)、5级31例(67.39%);GCS评分15分组GOS分级4级1例(4.35%)、5级22例(95.65%),组间差异具有统计学意义(χ~2=142.966,P=0.000)。结论高血压性脑出血患者入院时GCS评分与其预后呈正相关,GCS评分越高、GOS分级越高。     

Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years

BACKGROUND: Age and the Glasgow Coma Scale (GCS) score on admission are considered important predictors of outcome after traumatic brain injury. We investigated the predictive value of the GCS in a large group of patients whose computerised multimodal bedside monitoring data had been collected over the previous 10 years. METHODS: Data from 358 subjects with head injury, collected between 1992 and 2001, were analysed retrospectively. Patients were grouped according to year of admission. Glasgow Outcome Scores (GOS) were determined at six months. Spearman's correlation coefficients between GCS and GOS scores were calculated for each year. RESULTS: On average 34 (SD: 7) patients were monitored every year. We found a significant correlation between the GCS and GOS for the first five years (overall 1992-1996: r = 0.41; p<0.00001; n = 183) and consistent lack of correlations from 1997 onwards (overall 1997-2001: r = 0.091; p = 0.226; n = 175). In contrast, correlations between age and GOS were in both time periods significant and similar (r = -0.24 v r = -0.24; p<0.002). CONCLUSIONS: The admission GCS lost its predictive value for outcome in this group of patients from 1997 onwards. The predictive value of the GCS should be carefully reconsidered when building prognostic models incorporating multimodality monitoring after head injury.