【作者】 刘军；

【导师】 徐立新；

【作者基本信息】 中南大学 ， 临床医学， 2013， 硕士

【摘要】 目的：通过对重型颅脑外伤(severe traumatic brain injury, sTBI)血肿清除术后患者急性期7天内的体温干预,将体温控制在肛温36-37℃,观察患者颅内压、并发症、预后评分及缺血再灌注损伤(ischemia-reperfusion injury, IRI)相关因子IMA、MDA含量的变化,从而了解控制体温于肛温36-37℃治疗重型颅脑损伤是否有效,并进一步探讨体温控制的脑保护作用是否与减轻脑外伤血肿清除术后脑缺血再灌注性损伤的机制有关。方法：符合亚低温治疗适应症的重型颅脑损伤颅内血肿清除术后患者45例,随机分为体温控制治疗组(n=25)和对照组(n=20)。治疗组患者使用亚低温治疗仪及冬眠药物将重型颅脑损伤颅内血肿清除术后患者的体温控制在肛温36-37℃；对照组患者没有使用亚低温治疗仪控制体温,当患者体温超过38℃时,予以药物,冰敷等常规降温方法降温治疗维持正常体温。所有患者均行侧脑室外引流及颅内压监测(1次/2小时)；收集术后两组患者治疗前(即术后12小时,记为“0”)及治疗后第1、3、5、7天的血清标本,监测血清中缺血再灌注损伤相关因子IMA、MDA的含量变化;随访记录患者受伤治疗后3个月的GOS预后评分；记录两组患者并发症的发生情况。结果：1.两组患者颅内压比较：两组患者在治疗前即术后12小时颅内压较高,两组间颅内压无统计学差异,P>0.05；两组患者在治疗后第1天颅内压均达到峰值,治疗组治疗后第5天及第7天的颅内压平均值明显低于对照组,P<0.05。体温控制治疗组在治疗前即术后12小时升高,治疗后第1天达到高峰,治疗后第3天、第5天下降,第7天最低,治疗组治疗后第1天、第3天颅内压明显高于治疗前,P>0.05,治疗组治疗后第5天、第7天颅内压明显低于第1天,P<0.05;对照组在治疗前即术后12小时升高,治疗后第1天达到高峰,第3天仍持续,第5天开始下降,第7天最低,对照组治疗后第1天、第3天颅内压明显高于治疗前,P>0.05,对照组治疗后第7天颅内压明显低于第1天,P<0.05。2.两组患者血清中IMA浓度比较：治疗前两组患者血清IMA浓度均较高,无统计学差异,P>0.05；治疗组治疗后第1、3、5、7天血清IMA浓度明显低于对照组,两组间比较有显著性差异,P<0.05。体温控制治疗组治疗后第1、3、5、7天各个时间点的血清IMA浓度呈逐渐下降趋势,第7天和第1天比较有显著性差异,第1、3、5、7天与治疗前比较有显著性差异,P<O.05;对照组治疗后第1、3、5、7天各个时间点的血清IMA浓度有下降趋势,各个时间点两两比较无显著差异,治疗后各个时间点与治疗前比较亦无显著性差异,P>0.05。3.两组患者血清中MDA浓度比较：治疗前两组患者血清MDA浓度均较高,无显著性差异,P>0.05；治疗组治疗后第1、3、5、7天各个时间点血清MDA浓度明显低于对照组,两组间比较有显著性差异,P<0.05。体温控制治疗组治疗后第1、3、5、7天各个时间点的血清MDA浓度呈逐渐下降趋势,第5天和第1天以及第7天和第1天比较有显著性差异,第3、5、7天与治疗前比较有显著性差异,P<0.05。对照组治疗后第1、3、5、7天血清MDA浓度成缓慢下降趋势,第5天和第1天以及第7天和第1天比较有显著性差异,第5、7天与治疗前比较有显著性差异,P<0.05。4.两组患者的并发症发生率比较：体温控制治疗组血小板降低的发生率为4%、心律失常8%、消化道出血12%、低血钾20%、高血钠20%、肺部感染32%；对照组血小板降低的发生率为5%、心律失常5%、消化道出血10%、低血钾20%、高血钠20%、肺部感染30%,两组之间血小板降低、低血钾、高血钠、心律失常、消化道出血、肺部感染等并发症发生率比较,无显著性差异,P>0.05。5.两组患者GOS预后评分的比较：治疗组患者中良好占32%,中残占36%,重残占4%,植物生存的占16%,死亡的占12%,其中预后良好的比例为68%,预后不良的比例为32%；对照组患者中良好占25%,中残占10%,重残占35%,植物生存的占10%,死亡的占20%,其中预后良好地比例为35%,预后不良的比例为65%。两组间预后比较有显著性差异,P<0.05。结论：1.体温控制在肛温36-37℃可以降低重型颅脑损伤颅内血肿清除术后患者的颅内压,改善患者的预后；2.脑外伤颅内血肿清除术后患者伴有缺血再灌注性损伤,表现为缺血再灌注损伤相关指标IMA及MDA水平升高；3.脑外伤颅内血肿清除术后患者行体温控制治疗可明显降低IMA及MDA的浓度；4.脑外伤颅内血肿清除术后患者行体温控制治疗有脑保护作用,与降低IMA及MDA的浓度从而减轻缺血再灌注损伤有关。更多还原

【Abstract】 Objective:During acute phase of7days, the severe traumatic brain injury patients with intracranial hematoma removal procedure were maintained the body temperature at rectal temperature36～37℃by manual intervention. The study aims to observe the changes of intracranial pressure and prognosis and ischemia-reperfusion injury factor IMA, MDA of patients with sTBI and to investigate whether the control temperature treatment is effective on severe traumatic brain injury patients. And further to discuss whether the cerebral protective effect of controlling body temperature is related to the mechanism of alleviating cerebral ischemia reperfusion injury after the severe traumatic brain injury patients with intracranial hematoma had been removed.Method:A total of45severe traumatic brain injury patients (3<GCS≤8on admission) with intracranial hematoma removal surgery, who conformed to the indications of mild hypothermia, were randomly divided into the therapy group (n=25)and control group(n=20).In the therapy group, mild hypothermia therapy apparatus and hibernation drugs were used to control rectal temperature at36～37℃; while in the control group, No use of mild hypothermia therapy apparatus to control body temperature. When patients with a temperature over38℃, to give drugs、 ice and other conventional cooling methods to cool. All patients in both groups were underwent Lateral ventricular puncture and drainage. All patients’intracranial pressure was measured through the lateral ventricle pressure sensor dynamically. Collecting Serum specimen on the12h after nurosurgry and on1,3,5,7days after therpy; Monitoring the ischemia-reperfusion injury related factor of serum IMA> MDA concentration; Follow-up records the GOS score of patients3months after injury; Compared the complications incidence rate of two group patients.Result:1. The comparison of intracranial pressure between two groups: Intracranial pressure is higher before treatment (12hours after surgery) between the two groups, no statistically significant differences between the two groups (P>0.05); Intracranial pressure of the two groups attained the peak at the1st day after treatment, Intracranial pressure of therapy group was significantly lower than the control group at the5th and7th day after treatment, P<0.05. The intracranial pressure elevated at12hours after surgery in therapy group, and peaked at the1st after treatment, decreased at the3th and5th day, dropped to minmum at the7th day;The intracranial pressure at the1st and3th day was significantly higher than at12hours after surgery in therapy group, P<0.05, the intracranial pressure at the5st and7th day was significantly lower than at the1st day after surgery in therapy group, P<0.05; The intracranial pressure elevated at12hours after surgery in control group, and peaked at the1st after treatment, decreased at the5th day, dropped to minmum at the7th day. The intracranial pressure at the1st and3th day was significantly higher than at12hours after surgery in control group, P<0.05, the intracranial pressure at the7th day was significantly lower than at the1st day after surgery in control group, P<0.05.2. Serum IMA concentration Compare between the two groups before and after treatment:Serum IMA concentrations of the two groups were higher before treatment, no statistically significant differences between the two groups (P>0.05); The serum IMA concentration in therapy group was significantly lower than the control group at the1st,3th,5th,7th, P<0.05. Serum IMA concentration decreased gradually at the1st,3th,5th,7th in the therapy group:the7th day was significant lower than the1st day, and compared with before treatment, there were significant difference at the1st,3th,5th,7th day, respectively, P<0.05; Serum IMA concentration decreased at the1st,3th,5th,7th in the control group, there was no significant difference at each time point, P>0.05.3. Serum MDA concentration Compare between the two groups before and after treatment:Serum MDA concentrations of the two groups were higher before treatment, no statistically significant differences between the two groups (P>0.05); The serum MDA concentration in therapy group was significantly lower than the control group at the1st,3th,5th,7th, P<0.05. Serum IMA concentration decreased gradually at the1st,3th,5th,7th in the therapy group:the5th day and the7th day was significant lower than the1st day, respectively, and compared with before treatment, there were significant difference at the3th,5th,7th day, respectively, P<0.05; Serum IMA concentration decreased slowly at the1st,3th,5th,7th in the control group, the5th day and the7th day was significant lower than the1st day, respectively, and compared with before treatment, there were significant difference at the5th,7th day, respectively, P<0.05.4. The incidence of complications between two groups:There were complications during treatment in both groups, such as arrhythmia, thrombocytopenia, pulmonary infection, hypokalemia, hypernatremia and gastrointestinal bleeding etc. The complication rate of thrombocytopenia, arrhythmia, gastrointestinal bleeding, hypokalemia, hypernatremia and pulmonary infection in therapy group is4%,8%,12%,20%,20%,32%, respevtively; The complication rate of thrombocytopenia, arrhythmia, gastrointestinal bleeding, hypokalemia, hypernatremia and pulmonary infection in control group is5%,5%,10%,20%,20%,30%, respevtively. There was no statistically significant difference in the occurrence of thrombocytopenia, arrhythmia, gastrointestinal bleeding, hypokalemia, hypernatremia and pulmonary infection between the two groups, P>0.05. 5. The comparison of GOS between therapy group and the control group:In therapy group, the proportion of good recovery and moderate disability and severe disability and vegetative state and dead was32%,36%,4%,16%,12%respectively; while that in the control group was25%,10%,35%,10%,20%respectively. In therapy group, the proportion of good prognosis and poor prognosis was68%and32%; while that in the control group was35%and65%. The comparison between two groups was statistically significant differences, P<0.05.Conclusion:1.During acute phase of3-7days, the severe traumatic brain injury patients with intracranial hematoma removal procedure are maintained the body temperature at rectal temperature36～37℃by manual intervention. By this way, intracranial pressure could be reduced effectively; the prognosis of patients could be improved.2. Traumatic brain injury patients with evacuated hematoma had ischemia-reperfusion injury, showing that serum IMA and MDA levels elevated.3. Traumatic brain injury patients with evacuated hematoma underwent body temperature control treatment could significantly decrease the concentration of IMA and MDA.4. Traumatic brain injury patients with evacuated hematoma underwent body temperature control treatment had brain protective effect, which might be related with the decrease of IMA and MDA levels, thereby alleviate cerebral ischemia reperfusion injury.更多还原