| Section one Correlation between brainstem reflex findings and outcome in long-term unconscious patients with traumatic brain injuryBackground The fatality rate and mutilation rate of Traumatic brain injury are much high. Traumatic brain injury is a prevalent problem around the world which threatens the health of mankind. It is one of leading reasons of death and disability in young patients. Timely and proper treatment and nursing can increase the survival rate and have a good outcome. But a subdivision of the survival development into long-term unconscious patients. Patients with traumatic brain injury often had a poor prognosis, which brought a heavy burden to the social and patients’families. Only53.7%～63.0%patients recover consciousness after traumatic brain injury as reported. If there are reliable indicators to predict prognosis, we can strengthen the treatment of that patient who could be awake in order to shorten time the time of coma and early recover from consciousness. We can end the treatment as soon as possible to patients who are prompted by indicators of poor prognosis. It is reported that14%of the paitents still in unconscious state after one year, it takes one to seven billion dollars to maintain patients who are coma or vegetative state each year in the United States. A accurate prediction of the patients with traumatic brain injury is an urgent problem to the doctor and an urgent request of the patients’family. The family of patients can know the current situation and make decision about life support as soon as possible. It can properly make good use of medical resources. It is important for us to make an early, objective and accurate prediction to the coma patients with the development of medical ethics and in order to use medical resources much more effectively. Accordingly how to establish an effective, reliable and practicable model to predict the probability of weather the patients can awakening is an urgent problem. First of all, we can classify all patients according to the severity of diseases, and avoid the risk factors, we will greatly improve the medical treatment level in the future. Secondly, it can provide some accurate information of patients’ disease, which can guide doctors making decision and it is good for the allocation of the medical resources. With the development of our society more and more attention has been paid to this field, especially in the Foreign Countries. However, the research of our country is just at a start level, making a predictive model is an urgent problem for our country.Objective To explore the correlation between brainstem reflex (BSR) and outcome in long-term unconscious patients with severe traumatic brain injury(TBI).Methods The data were collected prospectively in60patients who suffered from severe TBI from March2010to June2011in the Southern Medical University, Zhujiang Hospital. These patients had a long-term disturbance of consciousness≥2weeks; age>16years old; without history of ear, brain injury, cardiopulmonary resuscitation, primary cerebral infarction. All of the patients’age, sex, cause, data of BSR performances and weather awakened or not were completely recorded.Examination and assessment standards in BSR:detection time(2week to6months after TBI), and at least three times of BSRs examinations were taked before the patients’awakening. The best state was acquire as the statistical data. Weather patients awakened or not after the sixth month from injury was used as the criterion.Abnormal criterion of BSR:The BSR can make homologue reaction through nervous reflex circuit after excite, so that BSR can Evaluate the functional status of central nervous system.There are ten kinds of BSR:VMR, CSR, CSR, FOMR, VOVR, PLR, CMR, CR, MR, HOVR, OCR. VMR and CMR are pathological reflexes, the other eight kinds of BSR are physiological reflex.The standard of conscious:We appraised the outcome of awakening in the patients as following:At least one of the traits is apparented or easy to identify, and it must be repetitively or consistently:1)Simple commands can be conducted.2)"Yes" or "No" with gesture or language can be replied.3) Words can be understood.4) Actions or emotional reactions in special environment are not caused by conditional reflexion.Statistical methods:All data were analyzed by SPSS13.0. Patients are divided into awakening group and coma group by sober or coma after the sixth month from injury. Chi square test test was used to find the indictors of prediction prognosis between two groups. P<0.05was considered as statistically significant.Results The research shows that36patients had awaked in60patients at the sixth month (the probabilities of awakening in these patients are60.0%). With21%of the abnormal index of BSR indicators.The unconsciousness rate as follows:L-VMR (43.75%); R-VMR (48.48%); L-CSR (76.40%); R-CSR (57.10%); L-FOMR (37.50%); R-FOMR (29.40%); L-VOVR (63.60%); R-VOVR (52.20%); L-PLR (90.00%); R-PLR (77.80%); L-CMR (55.60%); R-CMR (41.70%); L-CR (66.70%); R-CR (71.40%); MR (29.40%); L-HOVR (58.30%); R-HOVR (53.80%); OCR (100%)。There were significant differences between conscious and unconscious groups in the areflexia of left ciliospinal reflex, left vertical oculo-vestibular reflex, double light reflex, oculocardiac reflex. The unconscious probabilities were higher than those in the patients with abnormal BSR which mentioned above. There were no significant differences between other BSR.Conclusions1. The the findings of BSR can objectively and accurately demonstrate the degree of cerebral dysfunction and predict the prognosis of consciousness. 2. The patients with the absence of left ciliospinal reflex, left vertical oculo-vestibular reflex, double light reflex, oculocardiac reflex were difficult to become awakening. Section two The grading study of BSR in long-term unconscious patients after severe traumatic brain injuryObjective To analyze the manifestations of Brainstem reflex (BSR) and explore the value of BSR grading in prediction of awakening in unconscious patients after traumatic brain injury(TBI).Methods The data were collected prospectively in60patients who suffered from severe TBI from March2010to June2011in the Southern Medical University, Zhujiang Hospital. These patients had a long-term disturbance of consciousness>2weeks; age>16years old; without history of ear, brain injury, cardiopulmonary resuscitation, primary cerebral infarction. All of the patients’age, sex, cause, data of BSR performances and weather awakened or not were completely recorded.Examination and assessment standards in BSR:detection time(2week to6months after TBI), and at least three times of BSRs examinations were taked before the patients’awakening. The best state was acquire as the statistical data. Weather patients awakened or not after the sixth month from injury was used as the criterion.Abnormal criterion of BSR:The justification of abnormal BSR was the same as above.BSR grading in the study:Grade Ⅰ:did not appear the condition of Grade Ⅱ or Grade Ⅲ; or Grade ⅣGrade Ⅱ:one side light reflex were absent, or one side ciliospinal reflex were absent,or one side vertical oculo-vestibular reflex were absent;Grade Ⅲ:double ciliospinal reflex were absent, double vertical oculo-vestibular reflex were absent;Grade Ⅳ:double light reflex were absent, or oculocardiac reflex were absent. Glasgow Coma Scale:Opening Response: Spontaneous-open with blinking at baseline4points Opens to verbal command, speech, or shout3points Opens to pain, not applied to face2points None1pointsVerbal Response: Oriented5points Confused conversation, but able to answer questions4points Inappropriate responses, words discernible3points Incomprehensible speech2points None1pointsMotor Response Obeys commands for movement6points Purposeful movement to painful stimulus5points Withdraws from pain4points Abnormal (spastic) flexion, decorticate posture3points Extensor (rigid) response, decerebrate posture2points None1pointsGCS grading in the study:Grade I:patients with scores of13-15;Grade II:patients with score s of9-12;Grade III:patients with scores of3-8.The standard of conscious:We appraised the outcome of awakening in the patients as following:At least one of the traits is apparented or easy to identify, and it must be repetitively or consistently:1)Simple commands can be conducted.2)"Yes" or "No" with gesture or language can be replied.3) Words can be understood.4) Actions or emotional reactions in special environment are not caused by conditional reflexion. All statistical analyses were made with SPSS13.0. Kruskal-Wallis Test was used to deal with the relationship between BSR grading and outcome of awakening. Spearman correlation test was used to evaluated the correlation between BSR grading and outcome of awakening, P<0.05was considered had statistical significance. Sensitivity equal to actual conscious patients in prognosis conscious patients’actual conscious patients, specificity equal to actual unconscious patients in prognosis unconscious patients/actual unconscious patients.Results The study found:36patients had awaked in60patients at the sixth month(the probabilities of awakening in these patients are60.0%). The consciousness rate of BSR Grade I is88.9%; Grade Ⅱ is92.9%; Grade III is41.2%. Grade IV is0.0%. There were different in three grades of BSR grading using Kruskal-wallis test (x2=31.075, P<0.001); there difference existence between GCS grading and awakening (x2=36.000, P<0.001).There is a correlation between BSR grading and the probability of awakening in TBI patients when we used Spearman’s correlation test (r=-0.667, P<0.001). BSR grading was positively correlated with the probability of awakening in TBI patients, which indicated that the higher the grade, the smaller the probability of conscious. We set up our grading grade I and grade Ⅱ as indicator of easy awake, grade III and grade Ⅳ as indicator of not awake at6th month after severe traumatic brain injury, the sensitivity was87.5%, specificity was80.6%in our BSR grading, veracity was83.3%in our BSR grading. There were no patients in Grade I of GCS, and GCS can not use to predict weather patients will conscious or not(r=-0.123, P=0.349).Conclusion1. BSR grading standards can predict the probability of conscious objectively and accurately.2. BSR grading standards showed grade I have88.9%of patients awaking at6th month; grade Ⅱ probability of awaking have92.9%of patients awaking, grade Ⅲ probability of awaking dropped to41.2%,11patients who classified as grade IV couldn’t recover consciousness at6th month.3. We set up our grading grade I and grade Ⅱ as indicator of easy awake, grade Ⅲ and grade Ⅳ as indicator of not awake at6th month after severe traumatic brain injury, the sensitivity was80.6%, specificity was87.5%in our BSR grading, veracity was83.3%in our BSR grading. Section three Evaluation of prognosis in long-term unconscious patients after severe traumatic brain injury by Brainstem reflex gradingObjective To investigate relationship between using the Brainstem reflex grading and the prognostic among the patients with long term unconscious after severe traumatic brain injury.Methods The data were collected prospectively in60patients who sufferde from severe TBI from March2010to June2011in the South Medical University, Zhujiang Hospital. without case history of ear, brain injury, cardiopulmonary resuscitation, primary cerebral infarction. The BSR grading and GOS score after the6th month were completely recorded. Analysis the correlation between the BSR classification and the patients’GOS score. The patients with GOS5,4were considered who had a good prognosis, the patients with GOS3,2,1were considered who had a poor prognosis. BSR grading in the study:Grade Ⅰ:did not appear the condition of Grade Ⅱ or Grade Ⅲ; or Grade ⅣGrade Ⅱ:one side light reflex were absent, or one side ciliospinal reflex were absent,or one side vertical oculo-vestibular reflex were absent;Grade Ⅲ:double ciliospinal reflex were absent, double vertical oculo-vestibular reflex were absent;Grade Ⅳ:double light reflex were absent, or oculocardiac reflex were absent.Glasgow outcome scale (GOS) criterion:1point:death;2point:Vegetative state:unconscious, with a heartbeat and breathing, sometimes eyes open, sucking, yawning and other local motor response;3point:Severe disability:conscious, but the cognitive, speech and body movement are severely disabled, required others care in24-hour; 4point:Moderate disability:cognitive, behavioral and personality disorders; with mild hemiplegia, ataxia, speech difficulties and other disabilities, are still capable of independent reluctantly in their daily life, family and social activities;5point:Good recovery:able to re-enter normal social activities, and can return to work but may have all kinds of new sequels.Statistical methods:SPSS13.0statistical package used for statistical analysis. Kruskal-wallis test was used to analyze the correlation between the BSR grading and the patients’GOS score. P<0.05was considered significant.Results20cases with good prognosis,40patients with poor prognosis, total poor prognosis rate was66.67%;8cases died, the total mortality rate was13.33%.11cases with good prognosis and6patients with poor prognosis in grade I, poor prognosis rate was35.29%;8cases with good prognosis and7patients with poor prognosis in grade II, poor prognosis rate was46.67%;1cases with good prognosis and16patients with poor prognosis in grade Ⅲ, poor prognosis rate was94.11%.0cases with good prognosis and11patients with poor prognosis in grade IV, poor prognosis rate was100.00%. The BSR grading and GOS at least6months after the injury status by Kruskal-wallis test, χ2=21.141, P=0.000, the differences both had statistical significance, that is to say, the higher the grade, the worse the prognosis of patients. If the grade I and grade II is used as the indicator of good prognosis, grade Ⅲ and grade IV is used as the indicator of poor prognosis, the accuracy rate was76.7%.Conclusions1. The BSR grading can reflect the degree of brain injury objectively and accurately; the higher the classification, the more serious brain damage is, the worse prognosis is.2. If the grade I and grade II is used as the indicator of good prognosis, grade III and grade IV is used as the indicator of very poor prognosis, the accuracy rate was76.7%... |
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