创伤性脑损伤预后评估的争议与进展

doi:10.3877/cma.j.issn.2096-1537.2020.03.004

创伤性脑损伤（TBI）是世界卫生领域严重的全球性问题。因其居高不下的致死、致残率，导致患者遭受到包括身体、精神、情感和认知功能障碍等在内的多重损害，并给个人、家庭及社会带来沉重的负担。因此评估患者的预后对于评价患者的长期损害和病情恢复、预测患者和家属的医疗需求、比较多个医学中心的治疗结果、评估常规治疗和新方法的有效性及临床治疗效果都显得十分必要。TBI因致伤因子、损伤机制、临床表现的差异性、个体异质性等诸多因素的影响而使其预后呈现出复杂性和多样性。TBI评估领域涉及包括整体预后、意识恢复、生理功能、认知水平、精神状态、生活质量等在内的多个方面。但越来越多的研究发现，任何单一的指标不足以显示临床工作中的治疗效果，并使全面、多维的评估充满挑战。所以，在TBI预后转归评估方面采取整体的多层面标准化的多维预后评估极具挑战性。在TBI预后预测方面，将早期的损伤严重程度、受伤的机制、病理解剖的特征与TBI的多种预后因素、预测因子结合起来，建立出良好的动态的预后预测模型则显得尤为重要。这二者均是TBI预后评估领域的未来发展方向。本文通过对目前TBI预后评估领域较为常用的转归评估工具和预测工具进行了例举，并分别介绍了这些方法的运用价值。同时对当前TBI预后评估领域的发展及不足进行了讨论，进而对未来此领域的研究发展方向提出了展望。

关键词: 创伤性脑损伤, 预后评估, 预测分析

Traumatic brain injury (TBI) is a global health problem that has high mortality and morbidity and contributes to physical, mental, and cognition disorders, leading to heavy personal, family, and social burdens. Therefore, the prognostic evaluation of TBI patients is essential for assessing TBI patients' long-term injury and recovery, predicting the medical request of the patients and families, comparing analysis reports among medical centers, and evaluating the clinical effectiveness of routine and novel treatments. The prognosis of TBI is complex and variable due to differences in injury factors, injury mechanisms, and clinical symptoms, as well as individual heterogeneity. The evaluations of TBI includes outcomes, consciousness, physiological function, cognition, mental state, and quality of life. Many studies have suggested that a single indicator could not be enough to evaluate the clinical outcomes and clinical effect. And it is a big challenge to evaluate the prognosis of TBI through multi-step standardization and different dimensions analyses. The combination of early injury severity, injury mechanism, and pathological characteristic with the prognostic and predictive factors for TBI might bring up a good clinical dynamic model for prognosis prediction, which might be a direction to evaluate TBI in the future. This review addresses the outcome assessment of TBI using prognostic and predictive evaluation tools and discusses their applications. We also discuss the development of prognostic evaluation of TBI and the related shortcomings, and offer a new perspective for this area.

Key words: Traumatic brain injury, Prognostic evaluation, Predictive analysis

表1 部分TBI转归评估工具的内容及特点

评估领域	评价工具	特点
整体预后评估	GCS评分	简单、易行；主观性强；未包括瞳孔、脑干功能评价；气管插管无法判断语言
整体预后评估	格拉斯哥昏迷结局分量表（Glasgow outcome scale，GOS）或其扩展版评分（GOSE）	简单、易行；分类笼统；敏感度低
意识状态评估	急性期常用GCS评分	简单、易行；主观性强；未包括瞳孔、脑干功能评价；气管插管无法判断语言
	全面无反应评分量表（full outline of unresponsiveness，FOUR）	提供细节更多且更加精确；适用呼吸机辅助呼吸、无法进行言语能力评估的患者^[5]
	修订昏迷恢复量表（coma recovery scale revised，CRS-R）	适用急、慢性期严重意识障碍患者的意识判断；鉴别植物状态和最小意识状态
认知功能评估	蒙特利尔认知评估（montreal cognitive assessment，MoCA）	筛查轻度认知障碍，具有高敏感性、特异性
	简易精神状态检查（mini-mental state examination，MMSE）	适用有智能障碍且难以完成韦氏成人智力测验的患者
	Halstead-Reitan成套神经心理测验（HRB）	全面评估；花费时间较多
	洛文斯顿作业疗法认知评定成套测验（LOTCA battery）	效果肯定、项目简单、费时少；具有很好的信度和效度检验
心理功能障碍评估	韦克斯勒智力量表（WIS）	内容全面，可测量智力全貌和测量各种智力因素；测验起点偏难
	汉密尔顿抑郁量表（HDS）	评定方法简便，标准明确；不能较好鉴别抑郁症与焦虑症
	焦虑自评量表（Self-Rating Anxiety Scale，SAS）	评定焦虑症状的轻重程度，适用于有焦虑症状的成年人
日常生活能力评估	标准化基本ADL评定—Barthel指数	简单、灵敏度高、可信度高；用来预测治疗效果和预后
日常生活能力评估	复杂性的ADL—功能活动问卷（FAQ）	项目较全面，较好地反映患者在家庭和社会中的独立程度
生存质量评估	世界卫生组织生存质量评定量表（WHOQOL-100L）	具有好的信度、效度、反应度；有世界可比性

表1 部分TBI转归评估工具的内容及特点

评估领域	评价工具	特点
整体预后评估	GCS评分	简单、易行；主观性强；未包括瞳孔、脑干功能评价；气管插管无法判断语言
整体预后评估	格拉斯哥昏迷结局分量表（Glasgow outcome scale，GOS）或其扩展版评分（GOSE）	简单、易行；分类笼统；敏感度低
意识状态评估	急性期常用GCS评分	简单、易行；主观性强；未包括瞳孔、脑干功能评价；气管插管无法判断语言
	全面无反应评分量表（full outline of unresponsiveness，FOUR）	提供细节更多且更加精确；适用呼吸机辅助呼吸、无法进行言语能力评估的患者^[5]
	修订昏迷恢复量表（coma recovery scale revised，CRS-R）	适用急、慢性期严重意识障碍患者的意识判断；鉴别植物状态和最小意识状态
认知功能评估	蒙特利尔认知评估（montreal cognitive assessment，MoCA）	筛查轻度认知障碍，具有高敏感性、特异性
	简易精神状态检查（mini-mental state examination，MMSE）	适用有智能障碍且难以完成韦氏成人智力测验的患者
	Halstead-Reitan成套神经心理测验（HRB）	全面评估；花费时间较多
	洛文斯顿作业疗法认知评定成套测验（LOTCA battery）	效果肯定、项目简单、费时少；具有很好的信度和效度检验
心理功能障碍评估	韦克斯勒智力量表（WIS）	内容全面，可测量智力全貌和测量各种智力因素；测验起点偏难
	汉密尔顿抑郁量表（HDS）	评定方法简便，标准明确；不能较好鉴别抑郁症与焦虑症
	焦虑自评量表（Self-Rating Anxiety Scale，SAS）	评定焦虑症状的轻重程度，适用于有焦虑症状的成年人
日常生活能力评估	标准化基本ADL评定—Barthel指数	简单、灵敏度高、可信度高；用来预测治疗效果和预后
日常生活能力评估	复杂性的ADL—功能活动问卷（FAQ）	项目较全面，较好地反映患者在家庭和社会中的独立程度
生存质量评估	世界卫生组织生存质量评定量表（WHOQOL-100L）	具有好的信度、效度、反应度；有世界可比性

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