床旁超声监测视神经鞘直径评价重型颅脑创伤患者预后临床研究

Clinical application of optic nerve sheath diameter by bedside ultrasound in the prognosis assessment of severe traumatic brain injury

目的探讨床旁超声测量视神经鞘直径(ONSD)对重型颅脑创伤患者预后的评估价值。方法纳入2017年4月至2019年4月共78例重型颅脑创伤患者,入院后均行有创性颅内压监测和床旁超声ONSD测量,比较平卧位与30°头高位、通气治疗前30 min与治疗后30 min、甘露醇治疗前30 min与治疗后30 min双眼ONSD超声测量值;通过受试者工作特征(ROC)曲线分析ONSD超声测量值对重型颅脑创伤患者预后不良的预测价值。结果预后不良组[Glasgow预后分级(GOS)评分1~3分]患者入院后连续5 d平均颅内压高于预后良好组(GOS评分4~5分;t=2.111,P=0.038)。经30°头高位、通气和甘露醇治疗30 min,ONSD超声测量值分别低于平卧位(F=6.644,P=0.012)、通气治疗前30 min(F=4.492,P=0.037)和甘露醇治疗前30 min(F=5.552,P=0.021),而且预后不良组ONSD超声测量值高于预后良好组(体位变化:F=16.751,P=0.000;通气治疗:F=29.776,P=0.000;甘露醇治疗:F=12.465,P=0.002)。Pearson相关分析,治疗前平卧位ONSD超声测量值与颅内压呈正相关(r=0.691,P=0.000);ROC曲线显示,治疗前平卧位ONSD预测患者预后不良的曲线下面积为0.776(95%CI:0.826~0.978,P=0.000)、最佳临界值5.53 mm,灵敏度91.52%、特异度87.14%。结论床旁超声动态检测ONSD有助于早期评估重型颅脑创伤患者预后,指导制定降低颅内压的综合治疗策略。

Objective To evaluate the clinical value of bedside ultrasound measurement of optic nerve sheath diameter(ONSD)in the prognosis of severe traumatic brain injury(sTBI).Methods A total of 78 sTBI patients admitted to Department of Neurosurgery ICU of He’nan Provincial People’s Hospital from April 2017 to April 2019 were enrolled.Intracranial pressure(ICP)monitoring probe was placed when the patient was admitted,and bedside ultrasound was used to detect the ONSD.The values of ONSD in supine position and 30°head-up position,30 min before and after ventilation,and 30 min before and after mannitol treatment were observed and analyzed.Receiver operating characteristic curve(ROC)was used to analyze the predictive value of ONSD for unfavourable prognosis of sTBI patients.Results The mean ICP in unfavourable prognosis group[Glasgow Outcome Scale(GOS)score 1-3]was higher than that in favourable prognosis group(GOS score 4-5;t=2.111,P=0.038).After 30°head-up position,30 min after ventilation and mannitol treatment,the values of ONSD were lower than supine position(F=6.644,P=0.012),and 30 min before ventilation(F=4.492,P=0.037)and mannitol treatment(F=5.552,P=0.021),and ONSD in unfavourable prognosis group were higher than those in favourable prognosis group(posture change:F=16.751,P=0.000;ventilation treatment:F=29.776,P=0.000;application of mannitol:F=12.465,P=0.002).There was a positive correlation between ONSD and ICP(r=0.691,P=0.000).ONSD at 5.53 mm was the optimal threshold for unfavourable prognosis,the area under the curve(AUC)was0.776(95%CI:0.826-0.978,P=0.000).The sensitivity was 91.52%and the specificity was 87.14%.Conclusions Dynamic detection of ONSD by bedside ultrasound is helpful to evaluate the prognosis of sTBI,and guide the precise treatment of severe ICP.