经颅多普勒超声在评估中型颅脑创伤患者神经功能恶化中的作用

Application of transcranial doppler ultrasound in assessment of neurofunctional deterioration in moderate traumatic brain injury

目的探讨经颅多普勒超声(TCD)在评估中型颅脑创伤(mTBI)患者神经功能恶化中的作用。方法回顾性分析2012年10月至2017年6月空军军医大学第二附属医院神经外科收治的88例mTBI患者的临床资料。88例患者入院时格拉斯哥昏迷评分(GCS)为(10.3±1.1)分(9~12分),每8小时重新评估1次,GCS下降≥2分或病情发展需立即处置定义为神经功能恶化。所有患者入院后均经TCD监测颅内双侧大脑中动脉的脑血流动力学参数。采用单因素和多因素logistic回归分析法判断影响患者发生神经功能恶化的危险因素。进一步绘制受试者工作特征曲线(ROC)并计算曲线下面积(AUC),以评估独立危险因素的诊断效能。结果88例患者中,40例发生神经功能恶化,另48例未发生。单因素分析结果显示,年龄、入院GCS、CT分级及脑血流动力学参数[包括:搏动指数(PI)、舒张期血流速度(FVd)、收缩期血流速度(FVs)、平均流速(FVm)]可能为mTBI患者出现神经功能恶化的影响因素(均P<0.05)。多因素logistic回归分析结果显示,FVd(OR=0.873,95%CI:0.816~0.921,P<0.001)、FVs(OR=1.061,95%CI:1.026~1.104,P=0.001)及PI(OR=80.700,95%CI:1.600~716.200,P<0.001)为影响mTBI患者出现神经功能恶化的危险因素。通过绘制ROC可见诊断效能最高的是PI(AUC=0.869),其次为FVd(AUC=0.827);最佳截断值为PI>1.22,FVd<35.8 cm/s。结论初步推断作为无创、可重复、床旁监测手段,TCD监测的脑血流动力学参数可有效预警中型mTBI患者发生的神经功能恶化。

Objective To evaluate the clinical value of transcranial doppler ultrasound(TCD)in evaluation of neurofunctional deterioration(ND)in patients with moderate traumatic brain injury(mTBI).Methods A retrospective study was performed on 88 patients with mTBI admitted to Department of Neurosurgery,the Second Affiliated Hospital,Airforce Military Medical University from October 2012 to June 2017.The 88 patients had a Glasgow coma score(GCS)of 10.3±1.1 points(9-12 points)at admission.They were reassessed every 8 hours.ND was defined as a decrease in GCS of more than 2 points or rapid development requiring immediate surgical treatment.After admission,all patients were monitored by TCD for cerebral hemodynamic parameters of bilateral middle cerebral arteries.Univariate and multivariate logistic regression analyses were conducted to determine the clinical factors that affected ND.Furthermore,the receiver operating characteristic curve(ROC)was drawn and the area under the curve(AUC)was calculated for evaluation of the diagnostic efficacy of independent risk factors that affected the patients′ND.Results Of the 88 patients,40 developed ND,while the other 48 did not.Univariate analysis showed that age,GCS score at admission,CT grade and cerebral hemodynamic parameters(PI,FVd,FVs,FVm)may be influencing factors for ND in patients with mTBI(all P<0.05).Furthermore,multivariate logistic regression analysis showed that FVd(OR=0.873,95%CI:0.816-0.921,P<0.001),FVs(OR=1.061,95%CI:1.026-1.104,P=0.001)and PI(OR=80.700,95%CI:1.600-716.200,P<0.001)were independent risk factors that affected ND in patients with mTBI.By plotting ROC,we found that the highest diagnostic efficiency was PI(AUC=0.869),followed by FVd(AUC=0.827);the optimal cut-off values were PI>1.22 and FVd<35 cm/s.Conclusion As a noninvasive,repeated,bedside assessment tool,cerebral hemodynamic parameters of TCD can be effective predictive factors of ND in patients with mTBI.