脑弥漫性轴索损伤的诊断治疗及预后分析

Brain diffuse axonal injury:diagnosis,treatment and prognosis

目的分析脑弥漫轴索损伤（DAI）治疗及预后。方法选择经CT证实脑中线区域有出血灶的重型颅脑损伤住院患者50例，测算血肿体积、血肿距中线距离、首次腰穿脑脊液压力。Glasgow预后量表（GOS）评估预后。结果本组经治疗30-70d后清醒45例；在最长90d治疗期内，死亡3例，植物生存2例，重残2例、轻残4例、恢复良好39例。预后不良组（重残、轻残）和预后极差组（死亡、植物生存）在血肿容积和首次腰穿压力上的差异未达到统计学显著水平；而预后不良组和预后极差组在血肿距中线距离上均明显短于恢复良好组，预后极差组的血肿距中线距离长于预后不良组，但差异未达到统计学显著水平。预后良好患者占本组78％。结论创伤性脑中轴区域出血是DAI的关键病理改变，伤后早期深度、长程、昏迷是DAI典型临床特征，血肿距中线距离与DAI患者预后密切明显相关。对DAI患者，尽管没有实施手术，运用密切的生命体征监控和肺部管理措施，结合脱水、抗炎、神经营养药物等综合手段，恰当处理存在的合并伤，有效地控制可能继发的多器官功能衰竭，将可能收到良好的治疗效果。

Objective The treatment and prognosis of brain diffuse axonal injury （DM） were analyzed. Methods Fifty cases of severely head-injured patients with hemorrhage around cerebral midline who were confirmed by CT scan were included in this study. The hematoma volume, distance between hematoma and midline, and initial CSF pressure at initial lumbar puncture were detected. The prognosis was evaluated by Glasgow Outcome Scale （GOS）. Results There were 45 patients who recovered their consciousness with in 30 - 70 d. Within 90 days, there were 3 dead cases, 2 cases of vegetative state, 2 cases of severely／ disability, 4 cases of mild disability, and 39 cases with good recovery. The difference among poor recovery group （severe disability, mild disability）, extremely poor recovery group （dead, vegetative state）, and good recovery group at hematoma volume and initial CSF pressure was not statistically significant. But poor recovery and extremely poor recovery groups revealed significantly shorter distance than that of good recovery group. Although the distance between hematoma and midline in extremely poor recovery group was shorter than that of poor recovery group, there was no significant difference. The patients with good recovery accounted for 78% in all cases in this study. Conclusion The hemorrhage around cerebral midline is key pathological changes of DAI which shows clinically an earlier coma, deep coma, and prolonged coma. The distance between hematoma and cerebral midline is closely associated with DAI prognosis. Close monitoring of life signs, lung management, combined with dehydration, anti-inflammatory and neuroprotective drugs; and rational treatment of united injury, and effective control of maltiple organ failure will contribute to satisfactory prognosis of DAI patients.