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体感诱发电位及脑干听觉诱发电位对脑血管病患者预后的预测作用

作者 / Author:胡辉华

摘要 / Abstract:

目的 分析体感诱发电位(SEP)及脑干听觉诱发电位(BAEP)对脑血管病患者预后的预测作用。方法 选取许昌市中心医院收治的40例脑卒中昏迷患者,在患者昏迷早期分别进行SEP和BAEP检查,记录格拉斯哥昏迷评分(GCS),对预后进行分析。结果 SEP联合BAEP检测对脑血管病患者预后的敏感性96.0%,特异性100.0%,准确性97.5%,GCS评分对脑血管病患者预后的敏感性、特异性和准确性分别为72.0%、60.0%、67.5%;SEP联合BAEP检测的准确性、敏感性和特异性分别高于单独SEP、BAEP检测(P<0.05)。结论 SEP联合BAEP检测对脑卒中患者的预后判断具有较高的准确性。

关键词 / KeyWords:

体感诱发电位,脑干听觉诱发电位,脑血管病,昏迷

体感诱发电位及脑干听觉诱发电位对脑血管病患者预后的预测作用

胡辉华
许昌市中心医院,河南许昌 461000
作者简介:胡辉华,Email:2646235627@qq.com
 
摘要 目的 分析体感诱发电位(SEP)及脑干听觉诱发电位(BAEP)对脑血管病患者预后的预测作用。方法 选取许昌市中心医院收治的40例脑卒中昏迷患者,在患者昏迷早期分别进行SEP和BAEP检查,记录格拉斯哥昏迷评分(GCS),对预后进行分析。结果 SEP联合BAEP检测对脑血管病患者预后的敏感性96.0%,特异性100.0%,准确性97.5%,GCS评分对脑血管病患者预后的敏感性、特异性和准确性分别为72.0%、60.0%、67.5%;SEP联合BAEP检测的准确性、敏感性和特异性分别高于单独SEP、BAEP检测(P<0.05)。结论 SEP联合BAEP检测对脑卒中患者的预后判断具有较高的准确性。
关键词】 体感诱发电位;脑干听觉诱发电位;脑血管病;昏迷
中图分类号】  R743    【文献标识码】  A    【文章编号】  1673-5110(2019)04-0386-06  DOI:10.12083/SYSJ.2019.04.124
 
Predictive value of somatosensory evoked potential and brainstem auditory evoked potential in the prognosis of cerebrovascular disease patients
HU Huihua
Xuchang Central HospitalXuchang 461000,China
Abstract】  Objective  To analyze the predictive value of somatosensory evoked potential (SEP) and brainstem auditory evoked potential (BAEP) in the prognosis of patients with cerebrovascular disease.Methods  AForty coma patients were selected from the stroke patients admitted into our hospital,SEP and BAEP examination were performed respectivelyin the early stages of coma patientsand theGlasgow coma score (GCS) of patients were recorded,then the prognosis of patients were analyzed.Results  The sensitivity of SEP and BAEP combined detection to the prognosis of patients with cerebrovascular disease was 96.0%,the specificity was 100%and the accuracy was 97.5%,the sensitivity,specificity and accuracy of GCS score in predicting the prognosis of patients with cerebrovascular disease,was 72%,60%and 67.5% respectively,in addition,the sensitivity,accuracy and specificity of SEP and BAEP combined detection were higher than SEP or BAEP detection respectively,P<0.05.Conclusion  The combined detection of SEP and BAEP has high accuracy in the prognosis of patients with stroke,which can provide an Objective and reliable basis for predicting the prognosis of patients with cerebrovascular disease.
Key words】  Somatosensory evoked potential;Brainstem auditory evoked potential;Cerebrovascular disease;Coma
 
        随着我国国民生活水平的提升,脑血管病的发病率逐年上升,而脑血管疾病具有较高的致残率和致死率,同时脑血管疾病也是造成非创伤性昏迷的主要原因之一,昏迷患者主要有清醒、植物状态和死亡三种结局[1-4]。明确如何对昏迷患者的预后进行准确判断,可为临床治疗计划提供指导性意见,最终为患者提供更优质的服务。目前临床对于昏迷患者的预后主要通过格拉斯哥昏迷评分(Glasgow coma score,GCS)并结合CT检测及临床表现进行判断,但其预测结果与实际情况相差较大[3-8]。随着医学水平和科学技术的不断发展,临床开始使用体感诱发电位(somatosensory evoked potential,SEP)及脑干听觉诱发电位(brainstem auditory evoked potential,BAEP)检测脑干功能和大脑皮质功能,判断昏迷预后[9-12]。本研究分析SEP和BAEP检测对脑血管病患者预后的预测价值。
 
资料与方法
1.1  一般资料 搜集2015-03—2016-03许昌市中心医院收治的40例脑卒中后昏迷患者,男22例,女18例,年龄45~78(62.0±5.0)岁,患者入院后经CT检查确诊为脑卒中,排除伴周围神经病变、颈髓病变和耳部病变患者,GCS评分3~8(5.0±1.5)分,患者昏迷至入院时间2~15(8.0±2.0)h。
1.2  方法 患者入院后早期(昏迷72 h内)使用日本光电MEB-9404c肌电/诱发电位仪进行正中神经SEP检查和BAEP检测,并在入院后1~2周复查,同时记录GCS评分。
BAEP检测:患者仰卧体位,进行疏波短声刺激,将刺激强度设置为95 dB,以40 dB声强的白噪声掩蔽对侧耳,刺激频率设置为10 Hz,刺激后观察10~15 s,平均叠加1 000次,以头顶中央为参考电极(Cz),同侧耳垂为记录电极(A1或A2),前额正中为地线(Fpz),极间阻<2 kΩ,双侧节均重复检测2次,观察其重复性。
SEP检测:对两侧正中神经进行刺激,记录电极放置在对策头部的C3’或C4’(C3后C4向后1 cm)Erb点、Cv7棘突,于对侧的Erb点放置参考电极,地电极在前额Fpz点,刺激强度设置为20~25 mA,刺激频率1.9 Hz,扫描强度10 mm/Div,波宽0.3 ms,灵敏输入度20 μV/Div,带通100~450 Hz,平均叠加500次,予以重复检测2次,证明可重复性。
1.3  观察指标 BAEP检测主要观察双侧V波潜伏期(PL)、Ⅰ波、Ⅲ波、Ⅰ-Ⅲ波、Ⅲ-Ⅴ波间潜伏期(IPL)以及以上各波的分化情况。SEP检测主要观察P15、P25、N20、N13、N9各波的波幅分化和PL,并分析两侧的PL和N20波幅。
1.4  评价指标 BAEP检测异常标准:Ⅰ、Ⅱ、Ⅲ波形缺失或分化不良;Ⅲ或Ⅴ波任一波缺失或PL延长超过x±s;Ⅴ/Ⅰ波幅不超过0.5;Ⅲ-ⅤIPL/Ⅰ-ⅢIPL>1;Ⅰ-Ⅲ、Ⅲ-Ⅴ、Ⅰ-Ⅴ超过正常x±s。BAEP分级标准:Ⅰ级为正常,各波IPL、PL均正常;Ⅱ级为轻度异常,Ⅲ、Ⅴ波PL延长,Ⅴ/Ⅰ波幅不超过0.5,各波分化好;Ⅲ级为重度异常,波形异常,Ⅴ消失或难以确认;Ⅳ级为波形缺失,除Ⅰ波外,其余各波均消失。
SEP检测异常标准:P15、P25及N20未分化或波形分化差;P15、P25及N20波PL超过x±s;双侧波幅差均超过1/2。SEP分级标准:Ⅰ级为正常,各PL波正常,波幅和波形可;Ⅱ级为轻度异常,一侧SEP潜伏期略延长,或波形分化差,波幅低;Ⅲ级为重度异常,两侧SEP各波或一侧PL均延长,波形分化差,波幅低;Ⅳ级为形缺失,两侧或一侧的N20波消失。
GCS评分:Ⅰ级为死亡;Ⅱ级为植物生存;Ⅲ级为重度残疾,日常生活需要照料;Ⅳ级为轻度残疾但可独立生活;Ⅴ级为恢复良好可正常生活。
        检测指标良好且预后良好即为真阴性(true negative,TN),检测指标良好而预后较差即为假阴性(false negative,FN),检测指标结果为异常且预后效果差的患者即为真阳性(true positive,TP),检测指标为异常则预后较好的患者为假阳性(false positive,FP)。敏感性(SE)=TP/(TP+FN)×100%;特异性(SP)=TN/(TN+FP)×100%;准确率(AC)=(TN+TP)/检测总例数×100%。
1.5  统计学方法 统计学分析使用SPSS 22.0统计,连续性变量先进行正态性检验,若符合正态分布则以均数±标准差(x±s)表示,非正态分布以M(Q1~Q3)表示;计数资料以率(%)表示,采用χ2检验。P<0.05为差异有统计学意义。
 
结果
2.1  BAEP、SEP检测及GCS评分结果 见表1。
2.2  各项检测结果比较 SEP联合BAEP检测的敏感性、特异性和准确性高于单独SEP检测和BAEP检测及GCS评分判断结果,SEP、BAEP、GSS评分SEP联合BAEP检测结果差异有统计学意义(P<0.05)。见表2。
表1  脑卒中昏迷患者的BAEP、SEP检测及GCS评分结果  (n)
Table 1  BAEP,SEP and GCS scores in stroke patients with coma  (n)
方法 TN FN TP FP
BAEP 14 2 21 3
SEP 14 3 20 3
GCS评分 9 7 18 6
BAEP联合SEP 11 1 28 0
 
表2  各项检测结果比较  (%)
Table 2  Comparison of various test Results  (%)
方法 特异性 准确性 敏感性
BAEP 82.4ab 87.5ab 91.3ab
SEP 82.4ab 85.0ab 87.0ab
GCS评分 60.0a 67.5a 72.0a
BAEPSEP联合 100.0b 97.5b 96.6b
 注:与BAEP联合SEP检测比较,aP<0.05,与GCS评分比较,bP<0.05
 
讨论
        脑卒中后患者的病情进展较快,致残率和致死率高,脑卒中后造成的神经和脑组织损伤的程度是影响患者预后的决定性因素[13-20],如何对脑组织和神经的损伤程度作出准确判断,对于确定患者的治疗和康复计划有指导性意义。
        研究[21-26]发现,通过神经电生理检测可对脑损伤昏迷患者的损伤情况进行准确检测,从而对患者的预后作出指导性判断,因此SEP和BAEP也被广泛应用于脑血管病患者预后的预测中[27-33]。BAEP通过检测脑干的听觉神经传导通路反映脑干和听觉神经的功能,并能对脑组织的缺血状态、水肿情况和颅内压增高程度作出相对准确的判断。BAEP的原理是与计算机相结合,予以短声刺激,在中枢神经系统脑干部位的不同水平的信息进行搜集,对脑损伤患者进行的一种非损伤性诊断[34-40]。其电位波与脑组织特定的解剖结构有密切关系,Ⅰ波主要反映蜗神经的电活动,Ⅱ主要反映蜗神经核以听神经颅内段的电生理活动,也可反映桥延脑的边界情况,Ⅲ波可反映橄榄核的电活动和脑桥下部情况,Ⅴ波主要反映下丘、中脑下段和脑桥上段的情况,Ⅲ-Ⅴ波IPL延长表示脑干上段的听通路出现传导障碍,当Ⅲ-Ⅴ波消失而Ⅰ波存在提示脑干损伤,说明脑干有广泛性的结构损害,表示预后较差。虽然BAEP可较好地反映脑干听觉传导通路,但单纯进行BAEP仍会出现一定的误差,若病变部位只在大脑而未累及脑干,且无法反映大脑的电生理情况,患者若发病前存在听觉感受器和听神经损伤,也会影响检测结果的准确性;另外,各波的认定情况、耳机漏声以及刺激器存在输出障碍等技术性问题也会对结果造成影响[41-45]
        SEP的原理是对患者进行刺激感觉神经冲动,诱发感觉神经冲动沿着神经通路向经脊髓、丘脑传入大脑皮质产生的传导束及皮层的突触后电位引发反应,并沿着体感的传导路径向脊髓侧索,经脑干、视丘到达大脑皮质,可在刺激头皮的对侧相应部位记录到电生理活动,主要用于评估外围神经近端和整个中枢神经的传导通络是否出现障碍[42-48]。SEP检测可反映大脑皮质、皮质下的感觉传导通路的完整性和功能状态,不受治疗剂量、镇静剂和麻醉药物的影响,对判断脑血管病昏迷患者的预后具有较高价值。一般来说,若早期患者的P15、P25及N20波均消失,则病死率较高,特别是N20波消失患者预后较差。但在实际应用过程中患者身高、臂长和周围神经功能的传导速度不同,会对SEP检测结果的准确性造成影响[49-50]。因此,需将SEP与BAEP联合使用,以提高检测结果的准确性。
        SEP联合BAEP检测的结果准确性、敏感性和特异性均高于单独SEP、BAEP检测和GCS评分,说明SEP联合BAEP检测对判断患者的预后具有更高的价值。
 
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(收稿2018-11-28)
本文责编:夏保军
本文引用信息:胡辉华.体感诱发电位及脑干听觉诱发电位对脑血管病患者预后的预测作用[J].中国实用神经疾病杂志,2019,22(4):386-391.DOI:10.12083/SYSJ.2019.04.124

Reference informationHU Huihua.Predictive value of somatosensory evoked potential and brainstem auditory evoked potential in the prognosis of cerebrovascular disease patients[J]Chinese Journal of Practical Nervous Diseases201922(4)386-391.DOI10.12083/SYSJ.2019.04.124 

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