| Objective:The treatment of coma after severe traumatic brain injury(TBI)is difficult,important and hot in this field,and there is no recognized effective method so far.Right median nerve stimulation(RMNS)is a method for awakening which has been reported continuously in recent years,but its effectiveness has not been fully confirmed,and its mechanism of action has been rarely discussed.As a result,there is still a lack of reliable methods and theoretical basis for coma awakening at present.The purpose of this study was to investigate the effect of RMNS on early awakening after TBI,and to preliminarily explore the changes of miRNA expression in CSF of patients after early awakening.Methods:(1)Patients in TBI coma with onset of 1-2 weeks were randomly divided into treatment group and control group.Enrolled patients need to be satisfied(1)Glasgow coma scale(GCS)score ?8;(2)The exclusion of vital signs is not stable,intracranial infection,hydrocephalus and intracranial hematoma occupying effect did not lift.(2)Both groups were treated with conventional neurosurgery,and the treatment group was treated with RMNS on the basis of conventional treatment.In the treatment group patients before and 2 weeks after RMNS treatment are receiving GCS score,electroencephalogram(EEG),somatosensory evoked potential(SEP) and brainstem auditory evoked potential(BAEP)examination.Patients in the control group underwent the above electrophysiological examination at the same time point in the treatment group.EEG,SEP and BAEP were evaluated by Young modified grading,Judson grading and Hall grading,respectively.Coma recovery scale-revised(CRS-R)and Glasgow Outcome scale(GOS)were performed 1 month after onset.Five patients were randomly selected from the treatment group to undergo MRI diffusion tensor imaging(DTI)before and 2 weeks after RMNS treatment and measure the fractional anisotraphy(FA)in the brainstem.(3)Cerebrospinal fluid was collected from 5 patients in the treatment group who underwent DTI before and 2 weeks after RMNS treatment.Total RNA of cerebrospinal fluid was extracted and RNA was controlled.RNA library was constructed and controlled.High-throughput sequencing technology was applied to analyze the changes of microRNA(miRNA)expression in cerebrospinal fluid of TBI coma patients after awakening therapy with RMNS.The target genes of differentially expressed miRNA were predicted,and the gene ontology(GO)and Kyoto encyclopedia of genes and genomes(KEGG)signal pathways were analyzed.(4)statistical methods: SPSS 19.0 software was used for statistical analysis,and the measured data were expressed as mean standard deviation.T test is used for measurement data,chi-square test and rank-sum test were used for counting data.P < 0.05 was considered statistically significant.Results:(1)According to the inclusion and exclusion criteria,40 patients completed the test,including 20 in the treatment group and 20 in the control group.Before treatment,there were no statistical differences between the two groups in gender composition,age distribution,GCS score and whether surgery was performed (P > 0.05),and the two groups were comparable.(2)Two weeks after the awakening treatment,the GCS scores of the treatment group and the control group were 11.30±2.45 and 7.05±1.15,respectively,and the difference was statistically significant(P<0.05).EEG,SEP and BAEP of the treatment group were all better than those of the control group,and the difference was statistically significant(P<0.05).One month after the onset,CRS-R of the treatment group and the control group were 16.20±4.75 and 12.25±5.41,respectively,and the difference was statistically significant(P<0.05).GOS of the treatment group was superior to that of the control group,and the difference was statistically significant(P<0.05).The GCS and CRS-R of the 5 randomly selected DTI examination patients in the treatment group were improved,and the increase of brainstem FA was observed on DTI.(3)Among the 5 patients in the treatment group who underwent DTI examination,38 miRNA in cerebrospinal fluid samples were significantly different after 2 weeks of RMNS awakening compared with before treatment(Fold change 2,p-value <0.05),In patients with TBI coma,38 miRNAs in cerebrospinal fluid samples were significantly different 2 weeks after RMNS treatment compared with pre-treatment(Fold change 2,p-value <0.05),among which 34 miRNAs were up-regulated and 4 miRNAs were down-regulated.Top 5 up-regulated miRNAs(including: hsa-mir-204-5p,hsa-mir-532-5p,hsa-mir-574-5p,hsa-mir-1180-3p and hsa-mir-1298-5p)and down-regulated miRNAs(including:hsa-mir-145-5p and hsa-mir-182-5p)were selected for the prediction of target genes.And the most cross-linked target genes were found to be BIN2,MYZAP,CAMSAP2,DOCK9 and PPP4R2.GO analysis showed that differentially expressed miRNAs may be related to neuron growth,repair and nerve signal transmission.The signaling pathway of Tumor necrosis factor and dopaminergic synaptic have the highest correlation with differentially expressed miRNAs.Conclusion:(1)RMNS has an early awakening effect on coma patients after TBI,which can improve the prognosis;(2)After early awakening treatment with RMNS in patients with TBI coma,a series of miRNAs expressions in CSF changed,and these differentially expressed miRNAs may participate in specific biological processes after awakening treatment by regulating the expression of target genes.We speculated that it may play an early awakening role by reducing the apoptosis of nerve cells and increasing the level of dopamine. |
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