Clinical Study Of The Electroencephalogram Reactivity Joint Midbrain Morphology On The Prognosis Of Comatose Patients With Severe Traumatic Brain Injury

[Background]Traumatic brain injury (TBI) is one of the diseases that seriously threaten human health and life.As the increased consequent accidents by the development of China’s economic transportation construction business-. sports injuries and natural disasters,the incidence of head injury increased. At present, the annual incidence of traumatic brain injury is100/100000in our country, which has been close to developed countries. At present, with many other serious diseases (such as: infectious disease) endangering human health gradually got effective treatment and control, the incidence and fatality rate of TBI is still high, and its harm has become more and more prominent. As long as human activities exist, TBI can not be disappeared completely, there are important practical significance to reduce head injury and give maximum control and treatment of traumatic brain injury patients for maintaining the health of people. Because of the extremely high morbidity and fatality rate, Severe traumatic brain injury (STBI) has become a very important and hard problem in neurosurgical field. The patients with STBI are always very severe and stay in comatose state for a long time that seriously endangering the health of patients. As the treatment advances in technology, the mortality of severe traumatic brain injury patients with acute severe traumatic brain injury had a sharp decline.But the attendant problems come, severe traumatic brain injury patients after treatment is still in a long-term coma or vegetative state that bring a great deal of psychological and economic burden to the patient’s family. Maintaining the lives of comatose patients also need to spend a lot of social resources.Therefore, it is very important for the institution of clinical therapy to assess or predict the prognosis of patients with STBI, and the health resources in our country are limited and unevenly distributed at present, so the early prediction of the prognosis of comatose patients with STBI has highly practical significance.At present, a lot of researches have been done to assess the prognosis of comatos e patients with STBI at home and abroad, and the achievement is very remarkable. These researches mainly cover the following aspects: neuroethology and brainstem reflexes, imaging manifestations, physiological and biochemical index changes and neuro-electrophysiology detection.Neuro-electrophysiological detection has widely been used in clinical. Currently, in neuro-electrophysiological detections, which have been widely applied is electroencephalogram (EEG), brainstem auditory evoked potentials (BAEP) and somatosensory evoked potential (SEP). EEG detection is widely used in clinical which has played a good role in the patient’s condition and prognostic evaluation, it has aslo providid reliable objective basis for clinical diagnosis and treatment. Electroencephalogram (EEG) represents the electrical activity of cerebral cortex which CT、MRI and angiography can be revealed to display abnormal condition. Synek introduced the EEG reactivity grading standards first in1988,and get the confirms of Gutling’s study that the relationship between EEG reactivity and prognosis is significantly. The existence of the reactivity depends on brainstem reticular formation and thalamus cortex channel integrity. The operation of EEG is simple, safety and repeatable dynamic observation,therefore EEG is indispensable in the clinical detection and evaluation techniques. Imaging manifestation (such as: head CT and MRI) is the most commonly auxiliary examination in the clinical, which can assess the degree of brain injury and predict the prognosis of patients with TBI from the shape and structure of brain. Therefore, given the popularity of EEG and head CT, and it can provide useful reference information for clinician to judge the severity of patients, make clinical therapy and assess the prognosis of comatose patients, so, we adopt EEG reactivity and head CT scanning to assess the prognosis of comatose patients with STBI, at the same time, further explore the significance of EEG reactivity and head CT scanning to judgement of prognosis of comatose patients with STBI, which is convenient for clinical reference.[Objectives]The purpose of this study is to explore the relationship between EEG reactivity, midbrain morphology of head CT scanning and the prognosis of comatose ptients with STBI, through the analysis of EEG reactivity and midbrain morphology of head CT scanning in comatose patients with STBI.[Objects&Methods]1. General Data1.1Clinical Data:There were116comatose patients with STBI who admitted in Department of Neurosurgery, Huadu Hospital, Southern Medical University from April2011to October2012.78patients were male and38patients were female, aged from5to74years and averaged39.55±14.01years. All patients reached hospital in24hours. The initial Glasgow Coma Scale (GCS) is≤8, All patients were admitted within24h after injury, Glasgow coma scale (GCS) score on admission8points or less, among which72were traffic accident injury, hard object hit21cases, high falling injury in16cases, fall, fall in7cases; In116patients with69cases accepted surgery therapy. EEG monitoring for all patients under the condition of out of low temperature and the influence of drugs line (the after surgery patient from injury surveillance in48-72hours, monitoring time not less than30minutes;the non-surgical patients from injury surveillance in72hours, monitoring time not less than30minutes). When116patients admitted to hospital, one side of mydriasis in34cases,23cases of bilateral pupils scattered large. The length of hospital stay is from3to169days, averaged67.30±5.37days.1.2Criteria for Inclusion:①The patients reached hospital in24hours;②The patients were coma at admission, and GCS≤8;③All patients were underwent head CT examination at admission;④The typing of TBI is severe TBI;⑤Age:from5to75years old.1.3Criteria for exclusion:①The patients were had history of epilepsy;②The patients who had TBI, cerebral vascular accident, intracranial space-occupying lesions and intracranial infection history in the past;③The patients who had psychiatric history, drug or alcohol abuse history;④The patients who had a history of serious heart, lung, liver, kidney or other organ dysfunction;⑤The patients who had effect of sedative drugs;⑥The patients who abandoned treatment eventually in the follow-up.2. Experimental Method2.1We accurately measured the anteroposterior diameter and transverse diameter of midbrain of the comatose patients underwent head CT examination at admission, and then calculated the ratio of anteroposterior diameter and transverse diameter. EEG monitoring for all patients under the condition of out of low temperature and the influence of drugs(the after surgery patient from injury surveillance in48-72hours, monitoring time not less than30minutes). EEG records to give pain (press nasal septum) and sound stimulation (call near ear), judgjing EEG reactivity by visual.2.2The ratio of anteroposterior diameter and transverse diameter of midbrain measured at admission was divided into two groups:①0.9～1.1;②>1.1or<0.9. And at the end of the follow-up, the prognosis of the comatose patients with STBI according to the Glasgow outcome score (GOS) is divided into two groups:good prognosis group (GOS:4-5, prognosis is good and mild disability, respectively) and poor prognosis group (GOS:1-3, prognosis is severe disability, PVS and death, respectively). Through statistical analysis, we try to investigate the relationship between the ratio of anteroposterior diameter and transverse diameter of midorain and prognosis of comatose patients with STBI.2.3All patients in exclusion of low temperature and the influence of drugs were performed EEG reactivity in the early three days or less, EEG monitoring for all patients under the condition of out of low temperature and the influence of drugs line (the after surgery patient from injury surveillance in48-72hours, monitoring time not less than30minutes). EEG records to give pain (press nasal septum) and sound stimulation (call near ear), use visual judgement EEG Gutling reactive reference the change of the brain, such as spur, the rhythm of slow wave and wave of head-up for reaction, on both sides of the EEG recording does not change or suspicious as no response, we try to investigate the relationship between the EEG reactivity and prognosis of comatose patients with STBI.2.4EEG reactivity combined with the ratio of anteroposterior diameter and transverse diameter of midbrain was divided into four groups:①EEG reactivity positive and ratio0.9～1.1;②EEG reactivity dispositive and ratio>1.1or<0.9.③EEG reactivity positive and ratio>1.1or<0.9/EEG reactivity dispositive and ratio0.9～1.1. Trying to study the relationship between EEG reactivity combined with the ratio and prognosis of patients with STBI.2.5We calculate the sensitivity positive (SE)、specificity positive (SP) accuracy and error rates to represent the predictive value of EEG reactivity, ratio of anteroposterior diameter and transverse diameter of midbrain and their combination to prognosis of patients with STBI. true negative (TN):index is good and good prognosis of patients; False negative (FN):index was good and poor prognosis of the patients; True positive (TP):poor indicators and poor prognosis of the patients; false positive(FP):index and had good prognosis of patients; Sensitivity (SE)=[TP/(TP+FN)]×100%; Specificity (SP)=[TN/(FP) TN+]×100%.3, Statistical MethodsAll data using SPSS13.0statistics software to carry on the analysis, two independent sample rate compared with chi-square test, Significance level is a=0.05. P<0.05was considered as statistically different.[Results]1. The well prognosis rate of two different ratio groups was compared by the fourfold table Chi-square test, and showed statistically significant difference (x2-25.119,P=0.000).2. The well prognosis rate of EEG reactivity was compared by the fourfold table Chi-square test, and showed statistically significant difference (χ2=54.296. P=0.000).3. EEG reactivity combined with the ratio of anteroposterior diameter and transverse diameter of midbrain was divided into four groups. The well prognosis rate of three groups of EEG reactivity combined with the ratio was compared by the R×C table Chi-square test, and showed statistically significant difference (χ2=68.507, P=0.000).4. The sensitivity, specificity, accuracy, failure rate of the EEG reactivity for detection are83.67%,85.07%84.48%,8.62%,and the ratio of anteroposterior diameter and transverse diameter of midbrain for detection are75.51%,71.64%73.28%,16.37%. EEG reactivity combined with the ratio for detection are91.42%,89.58%,90.36%,5.88%.[Conclusions]1. There is a correlation between EEG reactivity and midbrain morphology and the prognosis of comatose patients with STBI, which can assess effectively the clinical prognosis of comatose patients with STBI.2. It can predict the clinical prognosis of the comatose patients with STBI effectively that EEG reactivity combined with the ratio of the anteroposterior diameter and transverse diameter of midbrain.