| BackgroundSevere traumatic brain injury (STBI) is a common trauma diseases in clinical neurosurgery work. In our country, the incidence of severe traumatic brain injury and the number of disability and death because of the severe traumatic brain injury also increased year by year. Intracranial pressure (ICP) is the pressure at cranial cavity wall generated by the cranial contents.There is increased intracranial pressure when supine adult intracranial pressure lasts for more than normal (15 mmHg).There are many factors causing the increase of ICP, the most common is traumatic brain injury. Because the suture in the cranial is close,the volume of cranial has been relatively fixed.It can provide the compensatory volume of relief is limited to increase of ICP,only about 8% of the volume of cranial cavity.Because acute craniocerebral trauma patients often have the large area of skull fracture, intracranial hemorrhage, extensive cerebral contusion, traumatic subarachnoid hemorrhage, traumatic cerebral infarction, cerebral edema, cerebral edema, hydrocephalus and other pathological phenomenon,it can lead to elevated ICP after the increased volume of brain more than the volume of compensatorc.It can cause brain shift or herniation and cause serious consequences when ICP continued to increase.Patients with severe traumatic brain injury usually appear in different degrees of increased intracranial pressure. Because of increased intracranial pressure and prognosis are closely related, so it is very important that we know the accurate values of ICP of the critical patients.We should perform the intracranial pressure monitoring in order to obtain accurate and objective ICP.In the United States and Europe, it is common that patients were performed the intracranial pressure monitoring with severe traumatic brain injury in the hospital.However, the intracranial pressure monitoring of patients with severe traumatic brain injury have not been popularized in China.Therefore, it will be important clinical significance to find the assessment of simple index with ICP.It had been confirmed that Neuron specific enolase (NSE), D-Dimer (D-D) and C-reactive protein (CRP) were new indexs of traumatic brain injury in recent years. But there were no related researchs about the NSE, D-D and CRP could reflect the ICP change.NSE exis in neurons,Specifically,may be used as a marker of nervous system damage material.NSE has the following characteristics when it has become one of the proteins related to nervous system. (1)NSE had a high specificity in neurons.NES can be used as the peripheral evidence of brain tissue damage when it appears and reaches a certain concentration in the blood and cerebrospinal fluid (CSF). (2) After neurons were suffered damage,NSE rapid releasing into CSF and (or) blood. (3)NSE has a certain time relationship with cerebral injury.(4)NSE has low correlation with gender and age.Because of these characteristics, NSE is used for the biochemical markers as brain injury. We can provide laboratory evidence for clinical assessment of brain injury degree through the detection of the content of NSE in blood and monitoring the changes of serum NSE. The present study shows that NSE can be used to predict the prognosis of patients with traumatic brain injury.D-D is the specific end product after cross linked fibrin be induced reaction by plasmin. The level of D-D increased significantly,In the secondary hyperfibrinolysis plasma,and D-D is the only indicators which directly reflects the degree of thrombin and plasmin generation. The body is in a blood hypercoagulable state after severe traumatic brain injury. Thrombosis start mass producing because the blood coagulation factor are consumption, and then the the fibrinolytic system can be activated.So it prompt a lot of plasmin appear in the blood, it can make the Cross-linked fibrin which has been formed into degradation. After it happen, D-Dimer will be produced. So D-D can accurately reflect the functional status of blood coagulation and fibrinolytic system when it can be used to determine the condition of the patients with severe traumatic brain injury.CRP is a typical reactive protein in inflammatory acute phase, it is synthesized in the liver. CRP concentration increased rapidly in the inflammatory process,CRP can be combined with the cell membrane choline phosphate in the presence of Ca2+.The combinative CRP can activate the classical pathway of complement.After severe brain injury, brain tissue is often severely damaged, blood brain barrier was severely damaged, the permeability of barrier increased.The structure and function of cerebral astrocytes and microglia cerebral astrocytes and microglia can occur damage in the role of damage factors in primary and secondary.Plenty of Interleukin-1 can be secreted and released into the blood and other elements of inflammatory factors by cerebral astrocytes and microglia. CRP synthesis increased in liver by the nterleukin-1 and inflammatory factor mediated.Therefore, the change of serum CRP concentration reflects the ability in some extent of stress reaction that body with raumatic brain injury. CRP is also considered to be a sensitive and specific index of brain cell injury in patients with severe traumatic brain injury acute age.The extent of neuronal damage, blood coagulation and fibrinolysis system disorder and acute inflammation ccould reveal the severity and prognosis of patients with severe traumatic brain injury. Therefore, NSE, D-D, CRP had became hot spots of research indicators of Department of neurosurgery in recent years.But the study was not reported that whether there was correlation between ICP and NSE, D-D, CRP in patients with severe traumatic brain injury,and NSE, D-D, CRP could be used as indicators of ICP.ObjectiveFrom monitoring the changes of ICP and changes of detection of peripheral blood NSE, D-D and CRP in patients after severe traumatic brain injury,we should hope to explore the correlations between ICP and the changes of NSE, D-D and CRP levels in patients with severe traumatic brain injury, and judge the NSE, D-D and CRP could be used as the indexes of ICP change. We could provide theoretical basis for diagnosis and treatment and illness judgment of patients with severe traumatic brain injury from the research.Methodsobjective:A serial of 35 patients with severe traumatic brain injury admitted to the department of neurosurgery of Jiangmen hospital affiliated to southern medical university from January 2012 to January 2014 were chosen as experimental group,including male 26 cases, female 9 cases. They ranged in age froml8 years to65 years old,averaged 37.20±12.45 years old.The causes of injury were traffic accident injury in 27 cases, high falling injury in 4 cases, falling injury in 3 cases, violence against injury in 1 cases. The average time of hospital arrival were (2.0±0.9)h。All the Glasgow Coma Scale (GCS) scores of 35 cases were<8,of which 18 cases were 6-8,17 cases were 3-5. All patients are necessary and indications for intracranial pressure monitoring.35 cases were proved to be a traumatic head injury by head CT,of which there were subdural hematoma in 13 cases, epidural hematoma in 7 cases, contusion and laceration of brain and (or) intracerebral hematoma in 15 cases, including diffuse axonal injury and injury cases of brain stem in 2 cases.28 cases were received emergency craniotomy operation, operation mode for craniotomy evacuation of intracranial hematoma, contusion and laceration of brain lesions and or bone flap craniotectomy decompression. Inclusion criteria:GCS 3～8; age ranged from 18～65 years old; start treatment time from injury within 4 h. Exclusion criteria: patients with shock or and other important organ injury combined with.Patients with hydrocephalus and intracranial infection diseases, cerebral ischemia, cerebral spinal cord lesions in the pre injury; patients with heart, lung, liver, kidney and other important organs disease; patients with endocrine disorders such as:diabetes, hyperthyroidism; patients with malignant tumor, autoimmune diseases, infectious diseases and hematopoietic system diseases; patients who had used the drug with the effect of coagulation and fibrinolytic within two weeks; female patients in the menstrual;patients with bilateral mydriasis;patients with less than 3 days of death in hospital.20 healthy people performed physical examination in the physical examination center of Jiangmen hospital affiliated to southern medical university at the same period were as controls, including 11 male cases,9 female cases, age ranged from 17～59 years old, average 35.20±11.25 years old.There were no significant difference between severe traumatic brain injury group and control gender and age (P>0.05), the two groups were comparable.ICP monitoring:The ICP monitoring was performed in 35 patients with severe traumatic brain injury after they were admitted to hospital within 3 hours. Sensor type:Camino 110-4HM (intraventricular type), USA Camino nerve protection company (Integra NeuroSciences company) products. Operation method:The site of puncture was selected in frontal horns of the lateral ventricle, namely the coronal suture before 1cm, the median sagittal line next 2.5 cm. In order to reduce the damage to the dominant hemisphere, the non craniotomy operation patients chose the right frontal and punctured, the craniotomy operation patients chose the frontal and punctured in the non operation side before the craniotomy operation. We cut the scalp before disinfection, put the skull drilling, cut the dura mater,put the intracranial pressure sensor directly into the ventricle.The direction was towards the image of external auditory canal and parallel to the sagittal plane,reached the ventricles depth was 4～6 cm. The probe was placed before the accurate zero, set the alarm value. After the probe was placed the safely,we stitched and bandaged incision.Then we connected the intracranial pressure monitor.Monitor model:Camino MPM-1 multi parameter monitor intracranial pressure monitor.The standard pressure of intracranial: slightly elevated 15-20mmHg increased moderately 21-40mmHg; severely increase>40mmHg. According to the different ICP,the group of 35 cases were divided into severely elevated ICP group(11 cases) and moderately elevated ICP group (24 cases).The detection of NSE、D-D、CRP:All procedures were strictly in accordance with the kit steps.NSE was detected by electrochemiluminescence immunoassay (ECLIA).The kit was German Roche Diagnostics Ltd products.Detection was performed using Roche Cobas e 601 automatic electrochemiluminescence immunoassay analyzer for detection, automatic generation of results.D-D was detected by immune turbidimetry.The Kit was the German Siemens Ltd products. Detection was performed using Japan (Sysmex) Corporation product SYSMEX CA-7000 automatic blood coagulation analyzer, automatic generation of results. CRP was detected by immune turbidimetry. The kit was German Roche Diagnostics Ltd products.Detection was performed using the Roche Cobas C 501 automatic biochemical analyzer, automatic generation of results.The patients with severe traumatic brain injury were took venous blood within 2h after they were admitted to the hospital, the control group cases were took venous blood on the examination day morning, three tubes of determination of each blood sample, average.The statistical method:All data were by analyzed using the SPSS 19 statistical software package.Continuous variables data were performed using the mean±standard deviation to express its distribution characteristics. Groupwise comparisons of continuous data were performed using Student’S t-test. The homogeneity test of variance was analyzed before multiple groups comparisons of continuous data were performed. Each groupwise comparisons of continuous data were performed using SNK-q in Homoscedasticity, and each groupwise comparisons of continuous data were performed using Tamhane’s T2 in Heterogeneity of variance.Multivariate data were by analyzed using Pearson correlation. NSE and ICP, D-D and ICP, CRP and ICP were analyzed by linear correlation analysis,NSE, D-D, CRP and ICP were analyzed with multivariant stepwise regression analysis.Variables were selected according to the alpha=0.05 level in multiple stepwise regression analysis. For statistical analyses, P<0.05 was considered significant.Results1. Comparison of NSE level in different ICP group of the patients with severe traumatic brain injury:The levels of NSE in the severely elevated ICP group, moderately elevated ICP group were obviously higher than those in the control group (P<0.05).The levels of NSE in the severely elevated ICP group were also obviously higher than those in the moderately elevated ICP group (P<0.05).2. Comparison of D-D level in different ICP group of the patients with severe traumatic brain injury:The levels of NSE in the severely elevated ICP group moderately elevated ICP group were obviously higher than those in the control group (P<0.05).The levels of D-D in the severely elevated ICP group were also obviously higher than those in the moderately elevated ICP group (P<0.05).3. Comparison of CRP level in different ICP group of the patients with severe traumatic brain injury:The levels of NSE in the severely elevated ICP group moderately elevated ICP group were obviously higher than those in the control group (P<0.05).The levels of CRP in the severely elevated ICP group were also obviously higher than those in the moderately elevated ICP group (P<0.05).4.The correlations were noted between the ICP and the changes of NSE, D-D and CRP levels in the patients with severe traumatic brain injury:There was a linear correlation between ICP and NSE in the patients with severe traumatic brain injury,A moderate positive correlation was between them(r=0.782, P=0.000).The regression was ICP=18.598+0.256NSE (t=7.200, P=0.000).There was a linear correlation between ICP and D-D in the patients with severe traumatic brain injury, A severe positive correlation was between them(r=0.873, P=0.000).The regression was ICP=10.779+23.955D-D (t=10.292, P=0.000.)There was a linear correlation between ICP and CRP in the patients with severe traumatic brain injury, A severe positive correlation was between them(r=0.826, P=0.000).The regression was ICP=9.932+0.771CRP (t=8.423, P=0.000).By multivariant stepwise regression analysis,ICP and NSE,D-D,CRP were indicated the most close correlation;ICP was only associated with D-D, the regression equations between ICP and D-D,ICP=10.779+23.955D-D (t=10.292, P=0.000) The multiple correlation coefficient R=0.873, The coefficient of determination R2=0.762, (F=105.917, P=0.000), The regression was ICP=10.779+23.955D-D (F=105.917, P=0.000).Conclusion1.The levels of NSE, D-D and CRP might be obviously elevated in the patients with severe traumatic brain injury. With the ICP increased, the NSE, D-D, CRP levels increased more obviously.2.The significant positive correlations could be noted between the ICP and the changes of NSE, D-D and CRP levels, and the most close correlation was between ICP and D-D in patients with severe traumatic brain injury.3.The levels of NSE, D-D and CRP in the patients with severe traumatic brain injury can be used as makers of elevated ICP and prognosis,guiding treatment. |
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