迁延性植物状态患者血清中多巴胺含量的临床意义

目的：探讨迁延性植物状态患者血清中多巴胺的变化及其临床意义。方法：用高效液相色谱测定长期昏迷的病人,并与正常对照组对比。结果：迁延性植物状态患者的血清中多巴胺显著降低。结论：多巴胺的减少可能是形成迁延性植物状态的重要因素之一。     

Patients in a persistent vegetative state: caregiver attitudes and reactions

OBJECTIVES: This exploratory study investigated the problems encountered by caregivers of long-stay hospital patients in a persistent vegetative state. MATERIAL AND METHODS: Sixteen primary caregivers completed questionnaires designed to assess their personality, psychophysical distress, coping strategies and caregiving-related problems. RESULTS: Males showed a higher level of emotional distress and neuroticism than females. All of the caregivers used situation-oriented coping strategies less over time. had apparently unsatisfactory family relationships, and their emotional distress increased with disease duration. The thoughts of the possible death of the patient were associated with anxiety and depressive symptoms. The caregivers' everyday lives were characterized by limited social relationships, and indoor and outdoor interests. CONCLUSION: Our study underlines the importance of psychosocially assessing PVS patient caregivers, who are often alone in coping with a irreversible situation. It also introduces a questionnaire (FSQ2) that seems to be sufficient to assess the caregiving-related problems.     

过度高压氧治疗对缺氧性脑病所致持续性植物状态预后的影响

目的研究过度高压氧治疗(HBO)对缺氧性脑病所致的持续性植物状态(PVS)患者预后的影响,探讨高压氧的治疗机制及过度治疗的不良影响。方法收集我院收治的缺氧性脑病致PVS患者60例,根据其高压氧治疗的病史分为常规HBO组,超长HBO组,未接受HBO治疗对照3组。以发病后6个月为观察点。观察指标包括PVS意识及预后评分(南京2001年版);改良Ashworth量表(MAS)评定;日抽搐次数;头CT/MRI中第三脑室宽度;颅内压;脑电图等。结果获得随访51例。3组患者在年龄、患病时间、意识及脑电图无显著性差异。第三脑室宽度及颅内压数据分析,超长HBO组的第三脑室宽度明显大于常规HBO组与对照组,同时颅内压较低,且这种差异在预后恢复有显著性差异(P0.05)。肌张力评定提示对照组及常规HBO组统计学分析无显著性差异。但与超长HBO组肌张力明显高于其他组,有显著性差异(P0.05)。超长组中抽搐次数较其他2组增加,但无统计学差异。结论高压氧治疗对脑损伤后意识恢复具有一定的疗效,但过度高压氧治疗可能导致脑昏迷患者严重的脑萎缩、巨大脑室及低颅压状态。形成不可逆、迟发性脑损伤,影响意识恢复。因此需合理、规范应用高压氧治疗。     

持续植物状态34例患者的评估

目的探讨准确、可靠、客观的床旁持续植物状态评估方法。方法对34例脑损害后昏迷转为持续植物状态的患者进行脑功能评估。临床指标包括意识状态、7项脑干反射、4项脑神经支配活动、3项脊髓反射、1项脊髓自动反射和2项脊神经支配活动；神经电生理指标包括脑电图（Youg分级评估标准）、脑干听觉诱发电位和短潜伏期体感诱发电位（Cant分级评估标准）。结果缺血缺氧性脑损害（30／34，88．2％）是最常见的脑损害原因。意识状态从早期浅度、中度或深度昏迷转为睁眼昏迷，脑干反射和脑神经支配的活动全部或部分存在，肢体自主运动部分存在或消失，脊髓反射全部或部分存在，脊髓自动反射全部或部分存在，脊髓病理反射部分阳性。脑电图判定Ⅰ级和Ⅵ级的分别为64．5％（20／31）和29．0％（9／31），Ⅲ级和Ⅳ级的共6．5％（2／31）。脑干听觉诱发电位判定Ⅰ级、Ⅱ级和Ⅲ级的分别为34．8％（8／23）、21．7％（5／23）和43．5％（10／23）。短潜伏期体感诱发电位判定Ⅰ级和Ⅲ级的分别为43．5％（10／23）和52．2％（12／23），Ⅱ级的仅4．4％（1／23）。全部34例患者中死亡10例（29．4％），在35～90d内意识清醒者4例（11．8％）。结论临床指标符合持续植物状态患者的脑功能状态存在差异，多项电生理技术的联合可对其做出准确、客观、可靠的评定，并为临床医疗决策提供重要参考意见。     

Transcranial electrical stimulation in patients with apallic syndrome

Muscle responses (MEPs) to transcranial electrical stimulation were studied in 7 patients with apallic syndrome. All the patients showed clinical signs of upper motor neurone impairment in the upper and lower limbs. MEPs were absent or markedly delayed in 4 of the 7 patients. Since patients with apallic syndrome show only minimal voluntary movement, transcranial stimulation is the only way to demonstrate abnormalities of fast corticospinal axons in these patients. Even though these patients often look similar clinically, with tetraplegia and decorticate or decerebrate posture, only some cases showed dysfunction of fast corticospinal neurons.     

Automated EEG entropy measurements in coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state

Monitoring the level of consciousness in brain-injured patients with disorders of consciousness is crucial as it provides diagnostic and prognostic information. Behavioral assessment remains the gold standard for assessing consciousness but previous studies have shown a high rate of misdiagnosis. This study aimed to investigate the usefulness of electroencephalography (EEG) entropy measurements in differentiating unconscious (coma or vegetative) from minimally conscious patients. Left fronto-temporal EEG recordings (10-minute resting state epochs) were prospectively obtained in 56 patients and 16 age-matched healthy volunteers. Patients were assessed in the acute (≤1 month post-injury; n=29) or chronic (>1 month post-injury; n=27) stage. The etiology was traumatic in 23 patients. Automated online EEG entropy calculations (providing an arbitrary value ranging from 0 to 91) were compared with behavioral assessments (Coma Recovery Scale-Revised) and outcome. EEG entropy correlated with Coma Recovery Scale total scores (r=0.49). Mean EEG entropy values were higher in minimally conscious (73±19; mean and standard deviation) than in vegetative/unresponsive wakefulness syndrome patients (45±28). Receiver operating characteristic analysis revealed an entropy cut-off value of 52 differentiating acute unconscious from minimally conscious patients (sensitivity 89% and specificity 90%). In chronic patients, entropy measurements offered no reliable diagnostic information. EEG entropy measurements did not allow prediction of outcome. User-independent time-frequency balanced spectral EEG entropy measurements seem to constitute an interesting diagnostic - albeit not prognostic - tool for assessing neural network complexity in disorders of consciousness in the acute setting. Future studies are needed before using this tool in routine clinical practice, and these should seek to improve automated EEG quantification paradigms in order to reduce the remaining false negative and false positive findings.     

成人低血糖脑病致持续植物状态一例

目的分析成人低血糖脑病的临床、电生理、影像学特点及预后。方法分析本院收治的1例低血糖脑病致持续植物状态患者临床资料。结果成人低血糖脑病多发生在应用胰岛素的糖尿病患者,有低血糖发作史的患者易再次发生,神经影像学改变可帮助评估病情严重程度。迅速恢复血糖水平是治疗的关键,低血糖持续时间长(超过6h),血糖最低1mmol·L~(-1),伴有持续高温,有明显皮质下病灶表明病情严重,均提示患者预后不良。结论严重的低血糖脑病可造成严重意识障碍,导致脑功能和结构不可逆的损伤,应该对高风险患者加强监测和及时处理,减少低血糖脑病的发生率、致残率及死亡率。     

微意识状态与持续植物状态疗效的对比研究

目的 探讨微意识状态(MCS)与持续植物状态(PVS)患者疗效的差异. 方法 深圳市第三人民医院自2004年2月至2011年3月收治脑外伤、脑出血致持续昏迷状态患者56例,其中临床判定MCS状态23例,余PVS 33例,患者均采用最新的药物、一体化系统综合康复促醒治疗,比较2组患者治疗前、治疗1、3、5个疗程后PVS量表评分和疗效,评定不同年龄段MCS患者疗效的差异. 结果 治疗3疗程、5疗程后MCS组患者PVS评分均高于PVS组,差异有统计学意义(P＜0.05).MCS组患者治疗1、3、5疗程后,PVS组患者治疗3、5疗程后PVS评分均高于治疗前,2组患者治疗5疗程后PVS评分均高于治疗1疗程,差异均有统计学意义(P＜0.05);2组患者疗效的差异有统计学意义(P＜0.05),由平均秩次判断,MCS组疗效较好;不同年龄段MCS患者疗效的差异有统计学意义(P＜0.05),其中18～29岁MCS患者疗效最好,＞50岁最差. 结论 MCS患者的治疗疗效明显好于PVS患者,一体化的系统治疗对于MCS患者很重要,可使多数患者意识恢复.     

猫脑外伤性持续性植物状态模型制作的实验研究

目的建立闭合性硬脑膜外占位性猫脑损伤后持续性植物状态(PVS)模型,探索其诊断标准。方法将水囊置放硬膜外模拟占位,然后向水囊内注入无菌水直到昏迷,并对动物模型进行评估。结果手术一个月后,有12只猫处于植物状态,动物模型的临床表现、体征等与PVS病人相近。结论本实验制作的PVS动物模型与临床病人相似,是一种比较理想的PVS动物模型。     

神经电生理在持续植物状态患者颈髓电刺激疗法中的应用

目的 探讨非创伤性颅脑损伤后持续性植物状态（PVS）患者多模式神经电生理（EEG、BAEP、SEP）的总评分与颈髓电刺激（cSCS）促醒治疗疗效的相关性.方法 回顾性分析2010年1月至2017年2月大庆油田总医院神经外科收治的48例cSCS促醒治疗的PVS患者（研究组）的临床资料、神经电生理评分、治疗1年后的疗效,并与同期保守促醒治疗50例患者（对照组）的临床资料、疗效进行对比分析.研究组多模式神经电生理总评分与cSCS促醒疗效的等级进行Spearman秩相关分析,观察二者的相关性.结果 促醒治疗1年后,研究组48例患者中脱离PVS18例（37.5％）,显效11例（22.9％）,好转10例（20.8％）,无效9例（18.7％）;对照组50例患者中脱离PVS 3例（6.0％）,显效4例（8.0％）,好转30例（60.0％）,无效13例（26.0％）.研究组和对照组疗效的Ridit分析显示,研究组R值=0.6077,对照组R值=0.3966,差异有统计学意义（P＜0.05）,cSCS促醒治疗的疗效优于保守促醒治疗.cSCS促醒疗效与神经电生理总评分进行Spearman秩相关分析显示,神经电生理总评分与cSCS促醒疗效呈显著的正向相关关系（rs =0.854,P＜0.05）,即神经电生理总评分越高,cSCS促醒的疗效越好.结论 （1）cSCS促醒技术可以促进神经功能的康复,提高脱离PVS的比率,有利于患者早期促醒PVS.（2）多模式神经电生理总评分与cSCS促醒疗效存在正相相关性,对临床选择cSCS促醒技术具有指导作用.     

The vegetative state/unresponsive wakefulness syndrome: a systematic review of prevalence studies

One of the worst outcomes of acquired brain injury is the vegetative state, recently renamed ‘unresponsive wakefulness syndrome’ (VS/UWS). A patient in VS/UWS shows reflexive behaviour such as spontaneous eye opening and breathing, but no signs of awareness of the self or the environment. We performed a systematic review of VS/UWS prevalence studies and assessed their reliability. Medline, Embase, the Cochrane Library, CINAHL and PsycINFO were searched in April 2013 for cross‐sectional point or period prevalence studies explicitly stating the prevalence of VS/UWS due to acute causes within the general population. We additionally checked bibliographies and consulted experts in the field to obtain ‘grey data’ like government reports. Relevant publications underwent quality assessment and data‐extraction. We retrieved 1032 papers out of which 14 met the inclusion criteria. Prevalence figures varied from 0.2 to 6.1 VS/UWS patients per 100 000 members of the population. However, the publications’ methodological quality differed substantially, in particular with regards to inclusion criteria and diagnosis verification. The reliability of VS/UWS prevalence figures is poor. Methodological flaws in available prevalence studies, the fact that 5/14 of the studies predate the identification of the minimally conscious state (MCS) as a distinct entity in 2002, and insufficient verification of included cases may lead to both overestimation and underestimation of the actual number of patients in VS/UWS.     

多抗甲素联合紫外线治疗持续性植物状态并发Ⅲ期褥疮的临床疗效观察

植物状态患者已失去正常人的某些生理功能而仅仅保留一些植物所具有的功能,如呼吸、新陈代谢等生长和发育功能,且这种状态持续达1个月及其以上称之为持续性植物状态[1].褥疮是由于局部组织长期受压,发生持续缺血、缺氧,营养不良而导致组织坏死的压力性溃疡,严重者甚至可发生败血症而危及生命.多抗甲素是由α-溶血性链球菌经深层培养提取精制所得的具有多种生理活性的多糖物质[2],能刺激机体的免疫细胞增强免疫功能,促进创面组织修复.紫外线具有消毒杀菌作用[3-4].紫光线光照射引起的生物学效应一般用最小红斑量(MED)表示.MED是紫外线照射24 h后产生刚可察觉到的红斑(JPE)或24 h后有清楚界限的红斑所需的最低照射剂量.花都区人民医院神经外科分别对30例持续性植物状态并发Ⅲ期褥疮患者采用紫外线照射、多抗甲素湿敷及两者结合的治疗方法,以探讨持续性植物状态并发Ⅲ期褥疮的较好的治疗方案.     

PET in coma and in vegetative state

Advances in resuscitation and critical care management have resulted in the survival of many patients despite severe brain damage. These patients may remain in coma or in vegetative state. The probability of recovery of conscious function is dependent on the extent of structural brain damage, which is difficult to assess by clinical, laboratory or functional tests. Positron emission tomography (PET) of 18F‐fluordeoxyglucose (FDG) can be used to investigate metabolic and functional impairment of the brain. In acute vegetative state (AVS, duration < 1 month), overall glucose utilization was significantly reduced in comparison with age‐matched controls. In a few cases with locked‐in syndrome, cortical metabolism was in the normal range. 11C‐Flumazenil (FMZ) measures the density of benzodiazepine receptors (BZRs) and thereby furnishes an estimate of neuronal integrity. PET with this tracer demonstrated a considerable reduction in BZRs in cortical areas, but indicated that the cerebellum was spared from neuronal loss. The comparison of FDG‐ and FMZ‐PET findings in AVS demonstrates that alterations of cerebral glucose consumption do not represent mere functional inactivation, but also irreversible structural damage. In some cases with minimally conscious state, auditory stimuli with emotional valence induced more brain activation (investigated by H215O‐PET) than meaningless noise; such studies can be used to detect residual cortical function. To improve prognostication of chances for recovery, a combination of functional activation studies and assessment of the extent of neuronal damage might be the optimal procedure and should be tested in larger cohorts of patients with comatose states of different severity.     

Sleep spindles in the initial stages of the vegetative state

The aim of this study was to look for the presence of spindling in the different stages of remission of the vegetative state to underline all possible correlations with lesional sites, severity of coma and final outcome. The nocturnal polygraphic recordings from 30 patients were examined: 20 (15M, 5F, mean age 31.7 years, range 16–41) had originally suffered a traumatic brain injury, 10 (4M, 6F, mean age 40.5 years, range 24–48) had hypoxic brain lesions. Evidence of spindling, always reduced in density and duration, was found in 44% of these patients, prevalently in the traumatic patients (53.3% versus 30% of hypoxic patients). No subjects in the full stage 0, 0–1 of the vegetative state (apallic syndrome) presented spindling. No significant correlation was found between spindling and the following parameters: gender, the time between the onset of coma and the polygraphic recording, or the site of the lesion.

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Sommario Scopo del lavoro è stato quello di osservare la presenza di fusi da sonno nei vari stadi di remissione dello stato vegetativo (sindrome apallica) e valutarne le eventuali correlazioni con le sedi della lesione, la severità del coma e l'outcome finale. Le registrazioni poligrafiche notturne sono state effettuate su 30 pazienti: 20 (15 maschi, 5 femmine, età media 31,7 anni, range 16–41) traumatizzati cranici, 10 (4 maschi, 6 femmine, età media 40,5 anni, range 24–48) con lesioni da ipossia cerebrale. La presenza di fusi da sonno sebbene ridotta di densità e durata, è stata riscontrata nel 44% dei pazienti, con una prevalenza nei traumatizzati cranici del 53,3% contro il 30% degli ipossici. Non sono stati riscontrati fusi da sonno nei primissimi stadi di remissione (0 e 0–1) dello stato vegetativo. Non è stata osservata alcuna correlazione tra la presenza di fusi da sonno ed i seguenti parametri: sesso, intervallo tra insorgenza del coma e momento della registrazione e sede della lesione.

     

Post-anoxic vegetative state: imaging and prognostic perspectives

Prognostic determination of patients in coma after resuscitation from cardiac arrest is a common and difficult requirement with significant ethical, social and legal implications. We set out to seek markers that can be used for the early detection of patients with a poor prognosis, so as to reduce uncertainty over treatment and non-treatment decisions, and to improve relationships with families. We reviewed the medical literature from 1991 to 2010, using key words such as post-anoxic coma, post-anoxic vegetative state, vegetative state prognosis, recovery after cardiac arrest. Neurological examination, electrophysiology, imaging, and biochemical markers are all useful tools for estimating patients' chances of recovery from cardiac arrest. It seems unlikely that any single test will prove to have 100% predictive value for outcome; but the combination of various prognostic markers, as shown in some articles, could increase the reliability of outcome prediction. However, further research is needed.     

Quantitative rates of brain glucose metabolism distinguish minimally conscious from vegetative state patients

The differentiation of the vegetative or unresponsive wakefulness syndrome (VS/UWS) from the minimally conscious state (MCS) is an important clinical issue. The cerebral metabolic rate of glucose (CMRglc) declines when consciousness is lost, and may reveal the residual cognitive function of these patients. However, no quantitative comparisons of cerebral glucose metabolism in VS/UWS and MCS have yet been reported. We calculated the regional and whole-brain CMRglc of 41 patients in the states of VS/UWS (n=14), MCS (n=21) or emergence from MCS (EMCS, n=6), and healthy volunteers (n=29). Global cortical CMRglc in VS/UWS and MCS averaged 42% and 55% of normal, respectively. Differences between VS/UWS and MCS were most pronounced in the frontoparietal cortex, at 42% and 60% of normal. In brainstem and thalamus, metabolism declined equally in the two conditions. In EMCS, metabolic rates were indistinguishable from those of MCS. Ordinal logistic regression predicted that patients are likely to emerge into MCS at CMRglc above 45% of normal. Receiver-operating characteristics showed that patients in MCS and VS/UWS can be differentiated with 82% accuracy, based on cortical metabolism. Together these results reveal a significant correlation between whole-brain energy metabolism and level of consciousness, suggesting that quantitative values of CMRglc reveal consciousness in severely brain-injured patients.     

A learning assessment procedure as a test supplement for monitoring progress with two post-coma persons with a diagnosis of vegetative state

Objective: Evaluating a learning assessment procedure for monitoring progress with two post-coma adults with a diagnosis of vegetative state.

Method: ABABCBCB and ABABCB designs were used for the two participants, with A representing baseline, B intervention and C control conditions. Participants’ activation of an optic microswitch by eyelid closure produced stimulation during B phases.

Results: One participant increased responding during B phases and decreased it during the C condition, suggesting a non-reflective minimal level of consciousness. She showed P300 and mismatch negativity responses and scored at the vegetative level on the Coma Recovery Scale-Revised (CRS-R). The other participant increased responding during the initial B phases without decline during the first (viable) part of the C condition, suggesting a pre-conscious level. He showed indistinct P300 and mismatch negativity responses and vegetative-level scores on the CRS-R.

Conclusion: Learning data seemed reconcilable with neurophysiological measures and more positive than CRS-R scores.     

Evaluation of technology-assisted learning setups for undertaking assessment and providing intervention to persons with a diagnosis of vegetative state

Objective: To evaluate the viability of technology-assisted learning setups for undertaking assessment and providing intervention to persons in vegetative state.

Method: Study I investigated whether three persons with a diagnosis of vegetative state could associate eye blinking or hand closure responses with contingent, positive stimulation, thus increasing their frequencies (showing signs of learning). Study II extended the learning process (introducing a new response and new stimuli) for one of the participants of Study I.

Results: Two of the participants of Study I succeeded in increasing their responses, indicating signs of learning. Study II showed that the participant (one of the two succeeding in Study I) acquired a new response to access new stimuli and could alternate this response with the one acquired in Study I.

Conclusion: Learning might represent a basic level of knowledge and consciousness. Detecting signs of learning might help modify a previous diagnosis of vegetative state and support intervention/rehabilitation efforts.