醫學六：80題 ( 包括麻醉科,眼科,耳鼻喉科,婦產科,復健科等科目及其及相關臨床實例與醫學倫理 )題庫下載題庫

PROGNOSIS — Outcome from severe head injury is dependent on a range of factors including baseline patient characteristics, severity of TBI, and the occurrence of medical complications and secondary brain insults. Specific negative outcome predictors that have been identified from these factors include [16,19-21,50,73,154,181-190]:

●Glasgow Coma Scale (GCS) score at presentation (especially the GCS motor score) (table 1)

●Full Outline of Unresponsiveness (FOUR) score (table 2)

●Presence and severity of computed tomography (CT) abnormalities (subarachnoid hemorrhage, cisternal effacement, mid...

PROGNOSIS — Outcome from severe head injury is dependent on a range of factors including baseline patient characteristics, severity of TBI, and the occurrence of medical complications and secondary brain insults. Specific negative outcome predictors that have been identified from these factors include [16,19-21,50,73,154,181-190]:

●Glasgow Coma Scale (GCS) score at presentation (especially the GCS motor score) (table 1)

●Full Outline of Unresponsiveness (FOUR) score (table 2)

●Presence and severity of computed tomography (CT) abnormalities (subarachnoid hemorrhage, cisternal effacement, midline shift, leukoaraiosis)

●Pupillary function

●Age

●Associated injuries and complications

●Hypotension

●Hypoxemia

●Pyrexia

●Elevated intracranial pressure (ICP)

●Reduced cerebral perfusion pressure (CPP)

●Bleeding diathesis (low platelet count, abnormal coagulation parameters)

Other studies are evaluating the potential of biomarkers, such as the levels of S-100β protein, neuron-specific enolase, and α-synuclein in the blood and/or cerebrospinal fluid (CSF), to predict neurologic outcome [191-193].

While some have attempted to develop outcome prediction models to guide decisions about withholding early treatment, the heterogeneity of severe head injury makes this difficult to apply to clinical decision making in individual patients [182,194,195]. Thus, except in the most extreme cases, a trial of early aggressive neurosurgical and neurocritical care management, including surgical removal of evacuable lesions and ICP monitoring, should be undertaken.

Cohort studies have suggested that patients with severe head injury (GCS ≤8) have approximately a 30 percent risk of death. At least one cohort study found that survivors of TBI continue to have a substantially increased risk of mortality for at least 13 years after hospitalization [196].

Only approximately 25 percent of survivors of severe TBI achieve long-term functional independence [73,181,197]. Approximately 5 to 15 percent of patients with severe TBI are discharged from acute care in a vegetative state [181,197,198]. Only half of these patients regain consciousness over the next year and virtually all of these patients remain severely disabled. Outcomes are somewhat better for those in the minimally conscious state. The persistent vegetative and minimally conscious states are described separately. The use of prognostic indicators for these outcomes is better defined for hypoxic-ischemic brain injury than for TBI [199]. (See "Hypoxic-ischemic brain injury in adults: Evaluation and prognosis", section on 'Persistent vegetative state' and "Hypoxic-ischemic brain injury in adults: Evaluation and prognosis", section on 'Minimally conscious state'.)

A randomized trial of amantadine (starting at 100 mg twice daily) in 184 patients admitted to inpatient rehabilitation in a vegetative or minimally conscious state after severe TBI found that amantadine treatment was associated with accelerated recovery during the four-week active treatment phase [200]. Rates of improvement subsequently slowed after treatment withdrawal in the amantadine group, and at week 6, disability scores in the two groups were similar. Further study is needed to determine a benefit for amantadine on long-term prognosis and its role in the treatment of patients with severe TBI. The mechanism of action for amantadine's putative effect is unclear; it is speculated that antagonism of N-methyl-D-aspartate and/or indirect agonism of dopamine may be involved.

Among patients with more moderate TBI, educational attainment is associated with an increased odds of disability-free recovery [201].