| Background With the development of economy and transportation,the morbidity of traumatic brain injury (TBI) is increasing year by year. Its treatment remains a great challenge, and the casualty and disable rate is the highest among serious trauma, so those cause the poor prognosis. At least 10 million patients with TBI worldwide are serious enough to result in death or hospitalization annually. In the United States, an average of 1.4 million TBI occur each year, and 50,000 deaths. There are about 1 million TBI patients every year in our country, and 100,000 of them can not survive the injury, and the most survivals are disabled, causing big burden on individuals and society as well. World Health Organization (WHO) prognosis says that in 2020, traumatism in traffic accidents will be in the third place among the main health care problems worldwide. So TBI has become the serious problem of public health. The progonsis of the patients after traumatic brain injury is the important thing which the patients'families and our clinicians cared, however, how to decrease the death rate and disable rate is a long-lasting tough problem in the field of neurosurgery. Many years foreign researcher devote themselves to search for the rehabilitative method of TBI, the exploration for vulnerate mechanism, clinical evaluation, auxiliary diagnosis, and treatment of TBI go extends ahead with the mode of foundation binding clinic constantly, while it is rarely in our country.So, how to estblish an effective, reliable and practicable model to predict the probability of patients'awakening is an urgent issue. So we can timely help after traumatic injury and correct means of early detection may improve the outcome after traumatic brain injury, decrease the level of disability in further life. In addition, we also can use the model to guide our clinical work and to make our system of medical service more stronger. Section one Quantitative electroencephalography in prediction of outcome of awakening in long-term unconscious patients after severe traumatic brain injuryObjective To explore the qunatitative electroencephalography in unconscious patients after severe traumatic brain injury (TBI) considering awakening.Methods 41 patients who were treated in our hospital after suffering from severe TBI were collected retrospectively. All case were divided into two groups:the awake group 19 cases (including 15 male cases and 4 female cases aged from 21 years old to 73 years old, average 43 years old) and the unawake group 22 cases (including 14 mal cases and 8 female cases aged from 21 years old to 68 years old, average 37years old).4 cases falled from high place,9 cases was hurted by object, 28 cases suffer from traffic accident.1. Inclusion critera:All cases suffer from TBI with duration of disturbance of unconsciousness>2 weeks and GCS score≤8. They had no history of TBI before, CPR, primary brain infarction, fracture of extremities and SCI.2. Exclusion critera:(1) Rectal temperature<32℃; (2)The drug of affectting the judgement of the function of brain obviously was used before assessment (calmative and sleep-promoting agent, anaesthetics, the junction of nerves-muscle blocking agent and antipsychotic); (3) Some diseases and factors maybe influence the function of brain (for example:metabolic disease, endocrine disease, intoxation, shock and so on).3. Conscious disturbance critera:(1) Can not open the eyes independently or also can not open the eyes post-stimulus or can open the eyes but can not trace obiect and not owing to palsy; (2) Can not act according to order; (3) Have no pronuncition that can be identified; (4) Have no movement for purpose. 4. The outcome of awakening after the sixth month from injury was used as the criterion. We appraised the outcome of awakening in patients as following:At least one of traits is apparent or easy to identify, and it must be repetitive or consistent: (1) Conducting simple commands. (2) Replying'Yes'or'No'with gesture or language. (3) Words can be understood. (4) Actions or emotional reactions in special environment are not caused by conditional reflexion.5. The method of collection EEG date:Two weeks after admission the original EEG were recorded in all patients using the electroencephalograph (KT88-2400) produced by company of Kangtai, which contains a built-in 19-electrode cap situated on the scalp according to the international 10-20 system.Impandence was kept exceeding 20KΩ. Frequency was set up to 30Hz.Each recording lastded more than 30min, which was acquired in the way of 12 channals (double ear lobe as reference electrode, Fpz as a ground electrode). The sample of 3 seconds was conllected each time in the original EEG that excluded the false waves resulting from the disturb of wink and electrocardia. The sum of the sample was 30 seconds. Then, the power spectrum that reflected the original EEG was harvested by means of the fast Fourier transform on the computer. The power spectrum was divided into 6 bandwidth by frequency.δ(1.0～4.0Hz),θ(4.1～8.0Hz),α1 (8.1～10.0Hz),α2 (10.1～13Hz)β1 (13.1～17.5Hz),β2 (17.6～35.0Hz). Calculate the value of absolute power in each band and the relative value ofδ+θ/α+βand research the correlation of the both groups. The awakening after the sixth months from injury was used as the criterion. For the cases who were operated unilateral decompressive craniectomy, the power spectrum was analysed on the side of decompressive craniectomy, while it was analysed on the both side, for the cases who were operated lateral decompressive craniectomy or not.6. Statistical approach:The measurable data was expressed using Mean±Standard Deviation. Levene homogeneity test for variance was performed between the two groups. All data were dealed with two independently sample t Test between the awake group and the unawakened prognosis group by SPSS 13.0. In the awake group, the value ofδ+θ/α+βand the GCS were tested by the method of K-S and Shapiro-Wilk. Both of them present bi variation normal distribution. The Spearman correlation analysis was also performed between the Glasgow coma score of the awake patients and the value ofδ+θ/α+βby SPSS 13.0. Selection size of tese a=0.05.Results We can draw a result as following:F=1.521, P=0.225 through the homogeneity test for variance of Levene. So we can think the two samples have a homoscedasticity. Then, using the two independent t test, both groups had significant difference, t=2.237, p=0.031. The value ofδ+θ/α+βis 5.432±3.277 in the awake group, while 8.724±5.641 in the unawakened group. Therefore, we can draw a conclusion that the value ofδ+θ/α+βin awake group is less than in the unawakened group. So the value ofδ+θ/α+βcan be saw as a predictor to assess the prognosis of the long-term unconscious patients after severe traumatic brain injury. In the awake group, the value ofδ+θ/α+βpresent unnormal distribution (P=0.014, P=0.057), the GCS present normal distribution (P=0.200, P=0.200). The Spearman correlation analysis was done between GCS and the value ofδ+θ/α+βin the awake group, r=-0.648, p=0.003, so we can see the both had negative correlation.Conclusions As an inexpensive, objective and rapid means of the evaluation of brain function, the QEEG can accurately reflect the degree of brain dysfunction and assess the prognosis of patients. Therefore, the greater the value ofδ+θ/α+βis, the more unfavours the prognosis is, on the contrary, the smaller the value ofδ+θ/α+βis, the more favours the prognosis. Section two The assessment of the prediction of long-term unconscious patients after severe traumatic brain injury using quantitative eletroencephalographyObjective To explore the quantitative electroencephalography in the long-trem unconscious patients after sereve traumatic brain injury considering prognosis, establish a method to assess the prognosis.Methods The original EEG datas of 41 cases after traumatic brain injury exceeding two weeks and 20 healthy adluts were collected respectively.41 cases after TBI were individed into the favorable prognosis group (30 cases) and the unfavorable prognosis group (11 cases) according the value of GOS. The sampled data did make fast Fourier transform to obtain the power spectrum analysis with the computer software. The power spectrum was divided into 6 bandwidth by frequency:δ(1.0～4.0Hz),θ(4.1～8.0Hz),α1(8.1～10.0Hz),α2(10.1～13H2),β1(13.1～17.5Hz),β2 (17.6～35.0Hz). The multiple linear regression was proformed between the value of GOS and the value of 8 band relative power,θband relative power, aband relative power,βband relative power andδ+θ/α+β. The discriminant function was established to assess the prognosis of 41 cases.1. Clinical data:In the 41 patients after suffering from severe TBI, there was 29 male cases (aged from 16 years old to 73 years old, average 37 years old) and 12 female cases (aged from 21 years old to 62 years old, average 40 years old).4 cases falled from high place,9 cases was hurted by object,28 cases suffer from traffic accident. In 20 healthy adults, there was 13 male cases (aged from 18 years old to 62 years old, average 38 years old) and 7 female cases (aged from 23 years old to 60 years old, average 44 years old). According to the GCS of the six months after brain injury, the 41 cases was divided into the favourable prognosis group (30 cases) and the unfavourable prognosis group (11 cases). The 20 healthy adults was classified into the healthy adults group.2. Inclusion critera:see the statement above.3. Exclusion critera:see the statement above.4. The method of collecting EEG date:see the statement above.5. Glasgow Outcome Scale (GOS) criteria:1 point:death;2 points:vegetative state:the unconscious, with a hearthbeat and breathing, eyes occasionglly, suck, yawn and localized motor response;3 points:severe disability:conscious but the cognitve, speech, body movement, severe disability,24 hours must require care;4 points:moderate disability:cognitive, behavioral, personality disorders;a mild hemiplegia, ataxia, speech difficultes and other disabilities, in everyday life, family and social activities are still capable of independent reluctantly;5 points:good recovery:able to re-enter normal social activities, and to return to work but can have a variety of new sequels.1-3points was saw as poor prognosis,4-5poins as good prognosis.6. Statistical methods:SPSS 13.0 statistical package used for statistical analysis. Multiple linear regression was used to analyze the correlation between the value of 8 band relative power,θband relative power,αband relative power,βband relative power andδ+θ/α+β,and the discrimination function was builted to assess the prognosis of the patients. Selection size of teseα=0.05.Results1. In the 41 patients, four cases'value of GOS was one point, eighteen cases' value of GOS was 2 points, eight cases'value of GOS was 3 points, nine cases'value of GOS was 4 points, two cases'value of GOS was 5 points. Multiple linear regression was used to analyze the correlation between the value ofδband relative power,θband relative power, aband relative power,βband relative power andδ+θ/α+β. The regression function as following: GOS=4.671-0.113(δ+θ/α+β)-0.023δ%-0.054α%+0.099β%The equation was tested, and it was considered significant (F=7.917, P=0.000). The coefficient of determination R2 was 0.468. In the five indexs, the value of 0 band relative power had no contribution to the equation. The standard partial regression coefficent was -0.515,-0.295,0.274 and -0.258 respectively, so the sequence of the rest indexs to affect the GOS from great to little is the value ofδ+θ/α+β,δband relative power,βband relative power, andαband relative power. The value ofδ+θ/α+βcan affect the value of GOS, P=0.006.2. According to the value of GOS after injury six months, the 41cases were divided into the favourable prognosis group(30 cases)and the unfavourable prognosis group (11 cases),20 healthy adults were referenced.So, the 61 cases can be individed into healthy adults group, the unfavourable group and the favourable group. The discriminatiory analysis was performed in the rest indexs. The Fisher discriminant function as following: The healthy adults group: P1=-109.079+1.875 (δ+θ/α+β)+0.715δ%+3.312α%+1.381β% The unfavourable prognosis group: P2=-26.704+1.065 (δ+θ/α+β)+0.592δ%+1.240α%+0.652β% The favourable prognosis group: P3=-24.763+0.703 (δ+θ/α+β)+0.549δ%+1.241α%+0.870β%The P value of the four indexes was all 0.000. The value of the a band relative power had largest difference in the four indexes,λ=0.050. The resting four indexes of a certain patient were entered into the above equations, the patient was distinguished through the resluts. The largest value was the group the patient should enter. The accuracy of the discriminant function is 85.2%, the effective is well. Conclusion Most TBI patients are young male patients, and traffic accidents were the major reason for the TBI.The most important factor affecting patients' prognosis is the severity of TBI which can be shown by the discriminant function accurately. |
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