高滲鹽水治療重型顱腦損傷后顱內壓與NSE的變化及臨床意義

洪德全　吳小霞　胡勇

[摘要] 目的 探討經高滲鹽水治療后患者重型顱腦損傷不同時間顱內壓的變化及血清神經元特異性烯醇化酶（NSE）變化及其臨床意義。 方法 收集我科2015年1月～2016年12月符合重型顱腦損傷診斷標準的患者90例，隨機將患者均分為7.5%高滲鹽水（HTS）組和甘露醇（M）組，分別用高滲鹽水和甘露醇進行脫水降顱壓治療，分別測量患者0 d（用藥前）、1 d、3 d、5 d、7 d顱內壓值及血清NSE含量，并對兩組組內及組間檢測結果進行統計學分析。 結果 高滲鹽水治療組中顱內壓較平穩，0 d（用藥前）、1 d、3 d、5 d、7 d顱內壓分別為（13.51±1.24）mmHg、（13.75±1.11）mmHg、（15.23±1.18）mmHg、（14.84±0.88）mmHg、（12.28±0.81）mmHg，而甘露醇治療組中顱內壓波動較大，0 d、1 d、3 d、5 d、7 d顱內壓分別為（13.97±1.27）mmHg、（14.02±1.18）mmHg、（19.02±1.25）mmHg、（17.79±0.96）mmHg、（14.06±0.88）mmHg；高滲鹽水治療組0 d（用藥前）、1 d 、3 d、5 d、7 d中血清NSE的量分別是（11.51±1.54）ng/mL、（12.16±1.81）ng/mL、（19.51±1.47）ng/mL、（16.32±1.36）ng/mL、（13.19±1.36）ng/mL；甘露醇治療組0 d、1 d、3 d、5 d、7 d血清NSE含量分別是（12.24±1.69）ng/mL、（24.21±2.04）ng/mL、（45.31±1.32）ng/mL、（28.34±1.41）ng/mL、（24.13±1.37）ng/mL。結果顯示高滲鹽水能有效且平穩降低顱內壓，兩組顱內壓變化無明顯差異（P>0.05），兩組組內各時間點顱內壓變化差異無統計學意義（P>0.05）。甘露醇治療組各時間點血清NSE含量明顯高于高滲鹽水治療組，兩組各時間點血清NSE含量有顯著差異（P<0.05）。兩組治療前GCS評分無明顯差異，治療后隨訪6個月可見HTS組預后較M組明顯好，差異有統計學意義（P<0.05）。 結論 高滲鹽水能有效且平穩地降低重型顱腦外傷后顱內壓，減輕患者的繼發性腦損傷，減少顱腦損傷后NSE含量，并能更有效地改善患者預后。

[關鍵詞] 顱腦損傷；高滲鹽水；NSE；顱內壓

[中圖分類號] R651.15 [文獻標識碼] A [文章編號] 1673-9701（2017）36-0015-04

[Abstract] Objective To investigate the changes of intracranial pressure and serum neuron specific enolase （NSE） in patients with severe traumatic brain injury treated with hypertonic saline and its clinical significance. Methods 90 patients who met the diagnostic criteria of severe head injury from January 2015 to December 2016 in our department were randomly divided into 7.5% hypertonic saline（HTS） group and mannitol （M） group equally. And the patients of two groups were treated with hypertonic saline and mannitol， respectively. The intracranial pressure and serum NSE levels were measured at 0 d （before treatment）， 1 d， 3 d， 5 d and 7 d respectively， and the intra- and inter-group test results of the two groups were statistically analyzed. Results The results showed that the intracranial pressure in hypertonic saline group was relatively stable， and the intracranial pressure at 0d （before treatment）， 1 d， 3 d， 5 d， 7 d were （13.51±1.24）mmHg，（13.75±1.11）mmHg，（15.23±1.18）mmHg，（14.84±0.88）mmHg，（12.28±0.81）mmHg. While intracranial pressure fluctuated significantly in mannitol group， and the intracranial pressure were（13.97±1.27）mmHg， （14.02±1.18）mmHg，（19.02±1.25）mmHg，（17.79±0.96）mmHg and（14.06±0.88）mmHg， respectively at 0 d， 1 d， 3 d， 5 d and 7 d respectively. The levels of serum NSE in hypertonic saline treatment group were （11.51±1.54），（12.16±1.81）ng/mL，（19.51±1.47）ng/mL，（16.32±1.36）ng/mL，（13.19±1.36）ng/mL， respectively. The levels of serum NSE in mannitol group were（12.24±1.69），（24.21±2.04 ）ng/mL，（45.31±1.32）ng/mL，（28.34±1.41）ng/mL，（24.13±1.37）ng/mL at 0 d， 1 d， 3 d， 5 d and 7 d respectively. The results showed that hypertonic saline can effectively and smoothly reduce intracranial pressure， and there was no significant difference in intracranial pressure between the two groups （P>0.05）. There was no significant difference in intracranial pressure between two groups at each time point （P>0.05）. The levels of serum NSE in mannitol group were significantly higher than those in hypertonic saline group at each time point， and the levels of serum NSE in both groups were significantly different at different time points（P<0.05）. There was no significant difference in the GCS score between the two treatment groups before treatment. After 6 months of follow-up， the prognosis of the HTS group was significantly better than that of the M group， and the difference was significant（P<0.05）. Conclusion Hypertonic saline can reduce intracranial pressure after severe craniocerebral injury effectively and smoothly， reduce secondary brain injury. It can also reduce NSE content after craniocerebral injury and can improve prognosis more effectively.

[Key words] Craniocerebral injury； Hypertonic saline； NSE； Intracranial pressure

重型顱腦損傷患者病情危重，容易導致顱內壓增高產生腦疝，最終導致患者死亡。重型顱腦損傷包含原發性顱腦損傷和繼發性顱腦損傷兩個病變過程，顱腦損傷后顱內壓增高程度及維持時間對患者的預后往往起著至關重要的作用[1]，快速有效地調控顱腦損傷患者的顱內壓以減少繼發性損傷，能有效提高患者的生存率。甘露醇是臨床上最常用的脫水降顱壓藥，但對于血壓不穩定的復合傷的重型顱腦損傷患者，用甘露醇脫水降顱壓可使血壓下降，進而減少腦組織的有效灌注，嚴重影響患者預后。有研……