JNS:植物状态和最小意识状态有治了?!

2018-05-29 杨中华 脑血管病及重症文献导读

2018年4月来自Darko Chudy等在JNS上发表了他们的研究结果,目的在于探讨DBS对于VS或MCS的疗效。

持续植物状态(Persistent vegetative state,PVS)首次由Jennett和Plum在1972年报道,定义为觉醒而无知觉(wakefulness without awareness)。多学会工作组(Multi-Society Task Force)制订了植物状态(vegetative state,VS)的标准:1.没有证据显示具有对自身或环境的知觉,不能与他人交流;2.没有证据显示具有对视觉、听觉、触觉或伤害性刺激的持续、可重复、有目的或自愿的行为;3.没有证据显示具有语言理解和表达能力;4.周期性觉醒状态如存在睡醒周期;5.下丘脑和脑干自主功能保留,即使在药物和护理的维持下;6.大小便失禁;7.脑神经反射(瞳孔、头眼、角膜、前庭-眼和gag反射)和脊髓反射不同程度地保留。工作组还认为创伤后PVS 12个月后不可能恢复意识,非创伤性PVS 3个月后恢复者极其罕见。

在2002年,Giacino等提出了一个新的概念-最小意识状态(minimally conscious state,MCS),特征为不一致但清晰可辨的意识行为证据,能够与昏迷或VS区别。

1969年Hassler等采用慢性深部脑电刺激(chronic deep brain electrical stimulation)试图提高患者的意识水平。纳入的患者为创伤21周仍然表现为去大脑皮层状态者,把电极放置在左侧丘脑前部(rostral part)和右侧内侧苍白球。经过19天的刺激,他们发现这种方法具有很强的唤醒作用以及其他方面的改善如自主运动;不过,并未达到意识水平的明显改善。

同一年,McLardy等报道了一例神经创伤后昏迷的患者,对桥脑网状结构的上部采用不同参数的电刺激,但是没有改善意识水平。1979年Sturm等对一名基底动脉瘤夹闭昏迷3周的患者采取了慢性电神经刺激,他们首次尝试双侧刺激,一个电极放置在左侧前侧丘脑(rostral thalamus),另一个电极放置在右侧丘脑内侧板前部(rostral part)。因为无效,拔除了右侧电极。左侧电极进行了为期7周的刺激后,患者能够执行简单命令,甚至能进行词语交流。

1993年Cohadon和Richer等对25例创伤后VS患者采用刺激中央丘脑束旁核(centromedian parafascicular [CM-pf] nuclei)的治疗方法。12例患者神经功能状态没有变化,随访1-10年后仍然保持VS。其他13例患者的意识都有不同程度恢复。作者认为深部脑刺激(deep brain stimulation,DBS)似乎能够加速患者的恢复,改善最终的执行能力。

九十年代后Tsubokawa和Yamamoto等对DBS治疗VS和MCS进行了深入研究。他们发表了纳入标准以及针对21例VS和5例MCS患者的DBS治疗结果。在VS队列中,2例患者定位于中脑的网状结构(楔状核),19例定位于CM-pf复合体。在MCS队列中,5例患者皆为CM-pf复合体。21例VS患者中8例从VS中恢复,能够通过语言或其他方式交流,但是在每天的日常活动都需要帮助,仍然长期卧床,严重残疾。Four of the 5 MCS patients emerged from the bedridden state.

Schiff等对一例DBS治疗的MCS患者进行了随访,取得了阳性结果。Magrassi等报道了3例意识障碍患者,采取双侧丘脑电刺激后痉挛状态和肌阵挛有改善,不过仍无意识行为。

2018年4月来自Darko Chudy等在JNS上发表了他们的研究结果,目的在于探讨DBS对于VS或MCS的疗效。

49例VS或MCS患者中14例纳入了该研究,并进行了DBS治疗。这14例患者中,4例为MCS,10例为VS;4例病因为脑外伤,10例为心脏骤停缺血缺氧性脑病。DBS的靶点为CM-pf复合体。随访38-60个月。

2例MCS患者意识恢复,能够步行,语言流利,生活独立。1例MCS患者到达了神志清醒程度,但是仍然需要轮椅辅助。1例VS患者恢复到了神志清醒程度,对简单命令有反应。3例VS患者死于并发症。其他7例患者意识水平没有明显改善。

最终作者认为MCS/VS患者自主恢复意识清醒水平并且日常生活不需要/极小需要辅助的可能性非常小。因此,对于适合的VS或MCS患者(上肢SEP、运动和脑干听觉诱发电位存在,PET显示脑糖代谢水平至多为低代谢水平[cerebral glucose metabolism affected not more than the level of hypometabolism]),DBS是治疗选择之一。

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    2018-09-06 xuyong535
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    2018-06-01 易水河

    知之为知之.时时刻刻都在前进

    0

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    2018-05-30 baihao215

    真是涨姿势了.不过还得慎重选择病例

    0

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    2018-05-30 张新亮1853311252142e2fm

    好文献.学习了

    0

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    2018-05-29 changjiu

    学习一下谢谢

    0

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    2018-05-29 清风拂面

    谢谢分享学习

    0

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    2018-05-29 wqkm

    ^_^^_^^_^

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