影響老年重型顱腦損傷患者預(yù)后的相關(guān)因素研究

黎華清 黎志洲 王天榮 蔡 慧

廣東省新興縣人民醫(yī)院神經(jīng)外科,廣東新興 527400

影響老年重型顱腦損傷患者預(yù)后的相關(guān)因素研究

黎華清 黎志洲 王天榮 蔡 慧

廣東省新興縣人民醫(yī)院神經(jīng)外科,廣東新興 527400

目的分析老年重型顱腦損傷患者的臨床資料,總結(jié)影響老年人重型顱腦損傷預(yù)后的因素,為提高重型顱腦損傷的治療水平提供科學(xué)的臨床依據(jù).方法回顧性分析我院收治的老年重型顱腦損傷患者117例,統(tǒng)計(jì)預(yù)后不良患者和預(yù)后良好患者的臨床資料,采用Pearson相關(guān)性分析影響預(yù)后的相關(guān)因素.結(jié)果患者的既往史、合并傷、環(huán)池情況、腦疝、術(shù)后并發(fā)癥、體溫、WBC計(jì)數(shù)、血糖水平、入院GCS評(píng)分、收縮壓是老年重型顱腦損傷患者預(yù)后相關(guān)因素(Plt;0.05).結(jié)論降低患者血糖水平、體溫,治療合并癥,改善機(jī)體缺血缺氧狀態(tài),降低顱內(nèi)壓,是提高患者生存率,改善預(yù)后的關(guān)鍵.

重型顱腦損傷;老年;相關(guān)因素;預(yù)后

近年來(lái),我國(guó)顱腦損傷的發(fā)生率已達(dá)到0.15%,其造成的死亡率居高不下.重型顱腦損傷(serious brain injury)占顱腦損傷總數(shù)的20%左右,隨著近年來(lái)的經(jīng)濟(jì)發(fā)展,重型顱腦損傷的發(fā)病率呈現(xiàn)逐年上升的趨勢(shì)[1].盡管隨著救治技術(shù)的發(fā)展,醫(yī)療水平的提高,重型顱腦損傷的預(yù)后仍不盡人意,特別是老年重型顱腦損傷患者這一特殊群體,其死亡率更是高達(dá)75%以上[2].本研究回顧性分析了117例老年重型顱腦損傷患者臨床資料,通過(guò)分析發(fā)現(xiàn)影響老年重型顱腦損傷患者預(yù)后的因素,現(xiàn)報(bào)道如下.

1 資料與方法

1.1 一般資料

本研究資料收集采用回顧性分析,選取2010年4月～2016年12月經(jīng)我院神經(jīng)外科診治的老年重型顱腦損傷患者117例,其中男78例,女39例,年齡65～91歲,平均(74.72±7.27)歲.

1.2 入選標(biāo)準(zhǔn)

(1)有頭部外傷史;(2)頭顱CT檢查確診為顱腦損傷;(3)符合顱腦損傷診斷標(biāo)準(zhǔn);(4)格拉斯哥昏迷評(píng)分法(Glasgow Coma Scale,GCS)≤8分,昏迷時(shí)間gt;6h.

1.3 觀察指標(biāo)

記錄患者一般資料,包括患者性別、年齡、既往史、有無(wú)合并傷、CT環(huán)池形態(tài)、有無(wú)腦疝、GCS評(píng)分、體溫、收縮壓、舒張壓、血糖水平、術(shù)后有無(wú)并發(fā)癥等.預(yù)后分級(jí)及格拉斯哥(GOS)預(yù)后分級(jí)標(biāo)準(zhǔn)見(jiàn)表1.

1.4 統(tǒng)計(jì)學(xué)處理

采用統(tǒng)計(jì)學(xué)軟件SPSS17.0版對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料采用()表示,采用t檢驗(yàn),計(jì)數(shù)資料采用百分?jǐn)?shù)(%)表示,采用χ2檢驗(yàn),相關(guān)分析采用Pearson相關(guān)性分析.Plt;0.05為差異有統(tǒng)計(jì)學(xué)意義.

表1 預(yù)后分級(jí)及GOS分級(jí)標(biāo)準(zhǔn)

2 結(jié)果

2.1 老年重型顱腦損傷預(yù)后相關(guān)因素統(tǒng)計(jì)

經(jīng)過(guò)χ2檢驗(yàn),患者的性別、年齡、既往史情況、是否有合并傷、CT檢查環(huán)池狀態(tài)情況、有無(wú)腦疝、入院GCS評(píng)分及術(shù)后是否有并發(fā)癥,在預(yù)后良好組和預(yù)后不良組之間差異有統(tǒng)計(jì)學(xué)意義(Plt;0.05),見(jiàn)表2.經(jīng)過(guò)單因素方差分析,患者的收縮壓、舒張壓、體溫、WBC計(jì)數(shù)、血糖水平在預(yù)后良好組和預(yù)后不良組之間差異有統(tǒng)計(jì)學(xué)意義(Plt;0.05),見(jiàn)表3.

表2 老年重型顱腦損傷患者預(yù)后情況相關(guān)因素統(tǒng)計(jì)(例)

表3 老年重型顱腦損傷患者預(yù)后情況相關(guān)因素統(tǒng)計(jì)(x ± s)

2.2 老年重型顱腦損傷預(yù)后相關(guān)因素相關(guān)分析

經(jīng)過(guò)單因素相關(guān)分析,老年重型顱腦損傷預(yù)后相關(guān)因素中,患者的既往史情況、是否有合并傷、CT檢查環(huán)池狀態(tài)情況、有無(wú)腦疝及術(shù)后是否有并發(fā)癥、體溫、WBC計(jì)數(shù)、血糖水平與老年重型顱腦損傷患者預(yù)后呈負(fù)相關(guān)(Plt;0.05),患者入院GCS評(píng)分、收縮壓與老年重型顱腦損傷患者預(yù)后呈正相關(guān)(Plt;0.05),患者性別、年齡、舒張壓與老年重型顱腦損傷患者預(yù)后不相關(guān)(Pgt;0.05).見(jiàn)表4.

表4 老年重型顱腦損傷預(yù)后相關(guān)因素相關(guān)分析

3 討論

3.1 年齡、性別與老年重型顱腦損傷預(yù)后的關(guān)系

眾多研究表明重型顱腦損傷患者的年齡是影響預(yù)后的一個(gè)重要因素[3-4].相對(duì)于年輕患者,老年患者各器官已呈現(xiàn)不同程度的衰退,如發(fā)生重型顱腦損傷,將會(huì)對(duì)老年患者產(chǎn)生極大的影響,老年患者預(yù)后往往不容樂(lè)觀.本研究表明,在gt;64歲的老年重型顱腦損傷患者中,年齡并不是影響預(yù)后的因素,這表明,當(dāng)重型顱腦損傷患者年齡超過(guò)64歲時(shí),其預(yù)后將不再受到年齡的影響,整體預(yù)后情況較差.但當(dāng)患者年齡超過(guò)75歲時(shí),預(yù)后情況顯著較64～74歲年齡段差,這提示,盡管當(dāng)重型顱腦損傷患者為老年時(shí),年齡已不再是預(yù)后相關(guān)因素,但是75歲可能是一個(gè)判斷預(yù)后好壞的分界線.以往研究表明,雌激素可有效減輕細(xì)胞凋亡,增加細(xì)胞鈣離子穩(wěn)定以及一定的神經(jīng)修復(fù)作用[5].本研究提示,在進(jìn)行老年重型顱腦損傷預(yù)后單因素分析時(shí),女性患者預(yù)后好于男性患者,但進(jìn)行相關(guān)分析時(shí),性別已不再是老年重型顱腦損傷預(yù)后相關(guān)因素,這可能與本研究的樣本選擇有關(guān),在今后的工作中還需要進(jìn)一步的擴(kuò)大樣本量.

3.2 既往史、合并傷與老年重型顱腦損傷預(yù)后的關(guān)系

以往研究表明,既往史與預(yù)后有相關(guān)性[6].本研究也證實(shí)了這一點(diǎn),這可能是因?yàn)樵谟谢A(chǔ)疾病的前提下,顱腦損傷可加重既往疾病,對(duì)患者預(yù)后產(chǎn)生不良影響.顱腦損傷的發(fā)生多是因?yàn)橥鈧蛘哕嚨溡?傷者往往合并其他部位的損傷,包括胸腹部創(chuàng)傷、骨折、額面部創(chuàng)傷甚至休克等.這些合并癥會(huì)加重患者失血和感染,以及疼痛的刺激都會(huì)對(duì)患者的預(yù)后造成影響[7].

3.3 環(huán)池狀態(tài)、腦疝與老年重型顱腦損傷預(yù)后的關(guān)系

重型顱腦損傷時(shí),腦組織多發(fā)生移位,造成鞍上池、腳間池、環(huán)池受壓,而環(huán)池受到壓迫后,腦脊液循環(huán)不暢會(huì)引起腦干受壓及顱內(nèi)壓升高,腦干損害可導(dǎo)致意識(shí)障礙的發(fā)生進(jìn)而影響患者的預(yù)后[8].顱腦損傷患者的腦組織水腫、顱內(nèi)血腫均可造成腦疝,而腦疝在以往的研究中已經(jīng)被證實(shí)與顱腦損傷預(yù)后顯著相關(guān)[9].本研究提示,環(huán)池狀態(tài)、腦疝與老年重型顱腦損傷預(yù)后的相關(guān)系數(shù)為-0.763和-0.621,相關(guān)性較高,這與眾多研究結(jié)果相一致.

3.4 GCS評(píng)分與老年重型顱腦損傷預(yù)后的關(guān)系

近年來(lái),GCS評(píng)分已被神經(jīng)外科醫(yī)生廣泛用于評(píng)估顱腦損傷患者預(yù)后的指標(biāo),可通過(guò)患者臨床表現(xiàn),如睜眼反應(yīng)、語(yǔ)言反應(yīng)、運(yùn)動(dòng)反應(yīng)來(lái)反映大腦活動(dòng),是作為顱腦損傷預(yù)后判斷的可靠指標(biāo)[10].本研究提示,GCS評(píng)分與老年重型顱腦損傷預(yù)后的相關(guān)系數(shù)為0.573,這與文獻(xiàn)報(bào)道一致.

3.5 并發(fā)癥與老年重型顱腦損傷預(yù)后的關(guān)系

顱腦損傷術(shù)后并發(fā)癥主要包括肺部感染、應(yīng)激性上消化道出血和嚴(yán)重內(nèi)環(huán)境紊亂等.這些術(shù)后并發(fā)癥聯(lián)合顱腦創(chuàng)傷、患者年齡,對(duì)患者的預(yù)后造成了顯著的影響.

3.6 患者其他因素與老年重型顱腦損傷預(yù)后的關(guān)系

當(dāng)患者發(fā)生顱腦損傷時(shí),由于失血、中樞性血壓調(diào)控紊亂、感染性休克等原因引起血壓異常,特別是收縮壓,由于血壓的改變,導(dǎo)致患者發(fā)生血氧平衡失調(diào),促使細(xì)胞凋亡[11-12].顱腦損傷后,受傷部位的白細(xì)胞大量聚集導(dǎo)致血管通透性改變,加劇水腫的發(fā)生[13].患者體溫的改變可引起顱內(nèi)糖代謝異常,大量乳酸堆積,加重繼發(fā)性損傷,影響患者的預(yù)后[14].顱腦損傷患者由于顱內(nèi)壓的改變,引起刺激大腦血糖中樞導(dǎo)致血糖升高,升高的血糖可引起腦細(xì)胞離子水平改變,鈉離子、鉀離子、碳酸氫根離子等出現(xiàn)細(xì)胞內(nèi)外分布不均,加重腦水腫,導(dǎo)致腦細(xì)胞死亡[15].

綜上所述,老年重型顱腦損傷的預(yù)后與患者的既往史情況、是否有合并傷、CT檢查環(huán)池狀態(tài)情況、有無(wú)腦疝及術(shù)后是否有并發(fā)癥、體溫、WBC計(jì)數(shù)、血糖水平與老年重型顱腦損傷患者預(yù)后呈負(fù)相關(guān),與患者入院GCS評(píng)分、收縮壓與老年重型顱腦損傷患者預(yù)后呈正相關(guān),臨床工作中應(yīng)在積極治顱腦損傷的同時(shí),降低患者血糖水平、體溫,治療合并癥,改善機(jī)體缺血缺氧狀態(tài),降低顱內(nèi)壓,提高患者生存率,改善患者預(yù)后.

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Study on related factors of prognosis in elderly patients with severe traumatic brain injury

LI Huaqing LI Zhizhou WANG Tianrong CAI Hui
Department of Neurosurgery,People's Hospital of Xinxing County,Xinxing 527400, China

ObjectiveTo analyze the clinical data of elderly patients with severe traumatic brain injury,to summarize the prognostic factors of severe craniocerebral injury in elderly patients,and to provide scientific basis for improving the level of treatment of severe traumatic brain injury.Methods117 elderly patients with severe traumatic brain injury in our hospital were retrospectively analyzed.Clinical data of patients with poor prognosis and good prognosis were analyzed.Related factors affecting prognosis were analyzed by Pearson regression.ResultsThe patient's past history,combined injuries,cisterna,brain hernia,postoperative complications,body temperature,WBC count,blood glucose level,admission GCS score,systolic blood pressure were related factors of prognosis in elderly patients with severe craniocerebral injury(Plt;0.05).ConclusionLowering blood glucose level,body temperature,treatment of complications,improving the state of ischemia and hypoxia,reducing intracranial pressure,is the key to improve the survival rate and prognosis of patients.

Severe craniocerebral injury;Elderly;Related factors;Prognosis

R651.15 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 2095-0616(2017)22-174-04

2017-09-08)