恢复期体感诱发电位对严重意识障碍儿童预后的预测价值

Functional and prognostic assessment of children with severe disorders of consciousness using convalescent somatosensory evoked potentials

目的探讨恢复期体感诱发电位(SEP)对多种获得性脑损伤(创伤、感染、缺氧等)所致的严重意识障碍儿童预后的预测价值。方法选取2013年7月至2021年12月在重庆医科大学附属儿童医院首次接受康复治疗,并完成SEP检查的286例严重意识障碍儿童,从电子病历中获取患儿的一般资料及SEP检查结果,按病因将其分为创伤性脑损伤组(103例)、颅内感染组(101例)、缺氧缺血性脑损伤组(42例)、其它病因组(40例)。通过随访获取患儿的意识状态及功能恢复情况,采用格拉斯哥结局量表(GOS)评估其病程1年时的功能结局,开展回顾性分析。结果随访时间最长至病程8年,随访期间死亡16人,其中1年内死亡4人。随访时病程满1年的患儿共191例,其中创伤性脑损伤67例、颅内感染63例、缺氧缺血性脑损伤30例、其它病因31例。病因分别为创伤性脑损伤、颅内感染、缺氧缺血性脑损伤时,双侧N20存在的患儿,其病程1年时的功能结局良好率高于单/双侧N20缺失的患儿(P<0.05)。对于创伤性脑损伤组,双侧N20存在对于良好结局的预测有一定作用,特异性为90.9%,敏感性为55.6%,阳性预测值为92.6%,阴性预测值为50%,阳性似然比为6.111。单/双侧N20消失不能准确预测不良预后。对于颅内感染组,双侧N20存在对于良好结局预测的特异性低,但单/双侧N20消失预测不良结局有一定作用,特异性为82.4%,敏感性为62.1%,阳性预测值为75%,阳性似然比为3.517。对于缺氧缺血性脑损伤组,双侧N20存在不能准确预测良好预后,而单/双侧N20消失预示不良预后,特异性87.5%,敏感性72.7%,阳性预测值94.1%,阳性似然比5.818。结论恢复期SEP对严重意识障碍儿童的预后有一定的预测价值。病因为创伤性脑损伤时,双侧N20存在可以作为预后良好的指标;病因为颅内感染或缺氧缺血性脑损伤时,N20消失提示预后不良。

Objective To explore the value of convalescent somatosensory evoked potentials(SEPs)in formulating a prognosis for children with severe disorders of consciousness(DOC)caused by brain trauma,infection or hypoxia.Methods This was a retrospective cohort study of 286 children with DOC children treated between 2013 and 2021.They were divided into a trauma group(n=103),an intracranial infection group(n=101),a hypoxia group(n=42)and an other-causes group(n=40).Their consciousness status and functional recovery were obtained in follow-up appointments,and their functional condition 1 year after discharge was assessed using the modified Glasgow Outcome scale(GOS).Results During 8-year follow-up,16 had died,with 4 deaths within 1 year.Among the 191 cases followed up to 1 year,children with a bilateral N20 SEP had significantly better functional outcomes than those with unilateral or bilateral N20 absence.For the trauma group,the presence of a bilateral N20 signal was a strong indicator of good functional outcome at the 1-year follow-up,with a specificity of 90.9%,sensitivity of 55.6%,positive predictive value(PPV)of 92.6%,negative predictive value(NPV)of 50%and a positive likelihood rate(PLR)of 6.111.However,for the intracranial infection group,the presence of N20 had a low specificity for predicting good outcomes,though the absence of an N20 potential predicted poor functional outcome at 1 year with a specificity of 82.4%,sensitivity of 62.1%,PPV of 75%,and PLR of 3.517.For the hypoxic group,bilateral N20 could not predict a good prognosis,though its absence meant a poor outcome,with a specificity of 87.5%,sensitivity of 63.6%,PPV of 93.3%,and PLR of 5.818.Conclusion SEPs during the recovery period can help to formulate a prognosis for children with severe DOC.Traumatic brain injury and the presence of bilateral N20 potentials can be used as a good prognostic indicator.For intracranial infection and hypoxic-ischemic brain injury,the absence of an N20 potential indicates a poor prognosis.