早期针刺治疗外伤性脑内血肿:随机对照研究
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摘要
目的:在常规西医治疗基础上,观察早期针刺治疗外伤性脑内血肿患者脑水肿的临床疗效并探讨其作用机制。方法:采用分层区组随机方法将64例格拉斯哥昏迷评分(GCS)6~12分患者分为针药组和西药组,每组32例。西药组采用常规脱水降颅压、神经营养等基础治疗,针药组在西药组治疗的基础上加用针刺治疗,穴取血海、太溪、丰隆、阴陵泉、足三里等,每天1次,6 d为一疗程,两疗程间隔1 d,共治疗4个疗程。于治疗前及治疗7、14、21、28 d时进行GCS评分并记录患者治疗期间的苏醒时间;治疗后90 d随访进行格拉斯哥预后分级(GOS)观察,统计病死率与有效生存率;于治疗前,治疗14、21、28 d时及治疗后90 d随访进行Barthel生活指数(BI)评分;于治疗前,治疗3、7、14、21、28天时进行头颅CT或MR扫描,计算脑水肿指数(BEI);于治疗前及治疗3、7、14 d时检测血浆炎性因子白介素6(IL-6)、神经肽Y(NPY)和一氧化氮(NO)含量。结果:(1)两组治疗过程中GCS评分呈逐渐升高趋势,治疗28 d与治疗前比较差异均有统计学意义(均P<0.05),治疗28 d GCS评分及平均苏醒时间组间比较差异无统计学意义(均P>0.05)。(2)随访90 d时针药组病死率为6.3%(2/32),西药组为9.4%(3/32,P>0.05);而有效生存率针药组为81.3%(26/32),高于西药组的59.4%(19/32,P<0.05)。(3)治疗28 d及随访90 d时两组BI评分均较治疗前升高(均P<0.05),且针药组优于西药组(均P<0.05)。(4)治疗14、21、28 d时两组BEI均较治疗前下降(均P<0.05),且治疗14 d时针药组较西药组下降更明显(P<0.05)。(5)治疗7、14 d时两组血浆IL-6、NPY、NO含量较治疗前下降(均P<0.05),且治疗7 d时针药组较西药组下降更明显(均P<0.05)。结论:在常规西药治疗基础上早期介入针刺可减轻患者脑水肿,改善预后,针药结合疗效优于单纯西药治疗。针刺作用机制可能与降低炎性反应的表达有关。
Objective To observe the effect of early acupuncture intervention on brain edema in patients with traumatic intracerebral hematoma and explore its mechanism on the basis of conventional western medicine. Methods With stratified block randomization, sixty-four patients with glasgow coma scale(GCS) of 6 to 12 were divided into an acupuncture combined with medicine group(a combination group) and a western medication group, 32 cases in each one. In the western medication group, dehydration to reduce intracranial pressure and nutritional nerves were given as the basic treatment. In the combination group, on the basis of the treatment as the western medication group, acupuncture was applied at Xuehai(SP 10), Taixi(KI 3), Fenglong(ST 40), Yinlingquan(SP 9), Zusanli(ST 36), etc. The treatment was given once every day, for 6 times as one course; there was an interval of 1 day between two courses; a total of 4 courses were required. GCS score and recovery time were recored before treatment and on the 7 th, 14 th and 28 th days. 90 days follow-up after treatment, the GOS was observed, and the mortality and effective survival rate were calculated. The Barthel index(BI) score was evaluated before treatment and on the 14 th, 21 st, 28 th days and 90 days follow-up after treatment. Before treatment and 3 rd, 7 th, 14 th, 21 st,28 th days, cranial CT or MR scan was performed to calculate the brain edema index(BEI); Plasma interleukin-6(6 IL-6), neuropeptide Y(NPY) and nitric oxide(NO) were measured before treatment and on the 3 rd, 7 th and 14 th days after treatment. Results(1) The GCS scores increased gradually in the two groups during treatment, and there was significant difference between the 28 th days and before treatment(both P<0.05). There were no significant difference between the two groups about GCS score and average recovery time on the 28 th days treatment(all P>0.05).(2) The mortality rate of the combination group was 6.3%(2/32) on 90 days follow-up, 9.4%(3/32) in the western medication group(P>0.05). The effective survival rate was 81.3%(26/32) in the combination group, which was higher than 59.4%(19/32) in the western medication group(P<0.05).(3) The BI score was significantly higher than that before treatment on the 28 th days and 90 days follow-up in the two groups(all P<0.05), and the result in the combination group was superior to that in the western medication group(both P <0.05).(4) The BEI decreased on the 14 th, 21 st and 28 th days in the two groups(all P<0.05), and on the 14 th day, the BEI decreased more significantly in the combination group than that in the western medication group(P<0.05).(5) The levels of IL-6, NPY and NO decreased on the 7 th and 14 th days in the two groups(all P<0.05), and decreased more significantly in the combination group than that in the western medication group on the 7 th day(P<0.05). Conclusion On the basis of conventional western medicine, early acupuncture can reduce cerebral edema and improve the prognosis of patients, and acupuncture combined with medicine are superior to western medicine alone. Acupuncture mechanism may be related to reducing the expression of inflammatory response.
Objective To observe the effect of early acupuncture intervention on brain edema in patients with traumatic intracerebral hematoma and explore its mechanism on the basis of conventional western medicine. Methods With stratified block randomization, sixty-four patients with glasgow coma scale(GCS) of 6 to 12 were divided into an acupuncture combined with medicine group(a combination group) and a western medication group, 32 cases in each one. In the western medication group, dehydration to reduce intracranial pressure and nutritional nerves were given as the basic treatment. In the combination group, on the basis of the treatment as the western medication group, acupuncture was applied at Xuehai(SP 10), Taixi(KI 3), Fenglong(ST 40), Yinlingquan(SP 9), Zusanli(ST 36), etc. The treatment was given once every day, for 6 times as one course; there was an interval of 1 day between two courses; a total of 4 courses were required. GCS score and recovery time were recored before treatment and on the 7 th, 14 th and 28 th days. 90 days follow-up after treatment, the GOS was observed, and the mortality and effective survival rate were calculated. The Barthel index(BI) score was evaluated before treatment and on the 14 th, 21 st, 28 th days and 90 days follow-up after treatment. Before treatment and 3 rd, 7 th, 14 th, 21 st,28 th days, cranial CT or MR scan was performed to calculate the brain edema index(BEI); Plasma interleukin-6(6 IL-6), neuropeptide Y(NPY) and nitric oxide(NO) were measured before treatment and on the 3 rd, 7 th and 14 th days after treatment. Results(1) The GCS scores increased gradually in the two groups during treatment, and there was significant difference between the 28 th days and before treatment(both P<0.05). There were no significant difference between the two groups about GCS score and average recovery time on the 28 th days treatment(all P>0.05).(2) The mortality rate of the combination group was 6.3%(2/32) on 90 days follow-up, 9.4%(3/32) in the western medication group(P>0.05). The effective survival rate was 81.3%(26/32) in the combination group, which was higher than 59.4%(19/32) in the western medication group(P<0.05).(3) The BI score was significantly higher than that before treatment on the 28 th days and 90 days follow-up in the two groups(all P<0.05), and the result in the combination group was superior to that in the western medication group(both P <0.05).(4) The BEI decreased on the 14 th, 21 st and 28 th days in the two groups(all P<0.05), and on the 14 th day, the BEI decreased more significantly in the combination group than that in the western medication group(P<0.05).(5) The levels of IL-6, NPY and NO decreased on the 7 th and 14 th days in the two groups(all P<0.05), and decreased more significantly in the combination group than that in the western medication group on the 7 th day(P<0.05). Conclusion On the basis of conventional western medicine, early acupuncture can reduce cerebral edema and improve the prognosis of patients, and acupuncture combined with medicine are superior to western medicine alone. Acupuncture mechanism may be related to reducing the expression of inflammatory response.
引文
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[3]Aronowski J,Zhao X.Molecular pathophysiology of cerebral hemorrhage secondary brain injury[J].Stroke,2011,42(6):1781-1786.
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[5]王忠诚.神经外科学[M].武汉:湖北科学技术出版社,2005:380-381.
[6]Shukla D,Devi BI,Agrawal A.Outcome measures for traumatic brain injury[J].Clin Neurol Neurosur,2011,113(6):435-441.
[7]王玉友.康复评定[M].北京:人民卫生出版社,2000:292-293.
[8]徐如祥.脑损伤神经功能损害与修复专家共识(2016)[J/OL].中华神经创伤外科电子杂志,2016,2(2):100-104.
[9]付小兵,费舟,冯华,等.中华战创伤学·颅脑战创伤[M].郑州:郑州大学出版社,2016:409-421.
[10]陈建华,李亚新,刘影.早期针灸治疗对重型颅脑损伤患者肢体运动功能的影响[J].中国针灸,2007,27(12):907-909.
[11]Skoglund K,Hillered L,Parins K,et al.The neurological wake-up test does not alter cerebral energy metabolism and oxygenation in patients with severe traumatic brain injury[J].Neruocrit Care,2013,17(1):57-59.
[12]李丽丽.活血涤痰汤对高血压脑出血神经功能恢复的影响[J].中国实验方剂学杂志,2015,21(4):189-192.
[13]谢林均,何迪,洪芬芳,等.一氧化氮与血管老化[J].南昌大学学报(医学版),2014,54(3):70-75.
[14]季艳琴,陈莉,孙树清.大鼠实验性脑损伤血浆NO含量及NOS活性改变及意义[J].交通医学,2012,26(3):213-216.
[15]岑波,胡飞,王建一.显微外科手术治疗外伤性脑内血肿[J].临床神经外科杂志,2013,10(4):203-204.
[16]程峰,张曙光,李晓良,等.外伤性基底节区脑内血肿45例临床分析[J].临床神经外科杂志,2014,11(6):466-468.
[17]周海哲.从《金匮要略》“血不利则为水”解析张学文教授论治颅脑水瘀证[J].新中医,2015,47(4):323-324.
[18]姚军.浅谈针刺活血化瘀的理论及临床应用[J].中国针灸,2015,35(4):3:89-392.
[19]郭新荣,王瑞辉,李娜,等.针灸治疗颅脑损伤用穴规律的现代文献研究[J].时珍国医国药,2013,24(6):1433-1434.
[20]王舒,钱宇斐,樊小农,等.“水沟”穴对脑缺血模型大鼠脑神经细胞坏死的影响——从形态学角度论证经穴的特异性[J].中国针灸,2009,29(9):733-738.
[21]孙华,赵慧,张捷,等.针刺百会、足三里对抑郁症患者血清炎性细胞因子水平的影响[J].中国针灸,2010,30(3):195-199.
[22]冀雨芳,杨丽珍.针刺对颅脑损伤昏迷大鼠NE和NO表达的影响及促醒作用机理初探[J].山西中医学院学报,2015,16(3):24-26.
[23]刘旭,杨衍宁,刘忠伦,等.针药结合治疗脑出血及对S100B蛋白、神经肽?和脑水肿的影响[J].中国实验方剂学杂志,2012,18(10):295-297.
[2]李琛,李国辉.急性脑梗死患者血清高敏C反应蛋白水平与脑水肿严重程度的相关性[J].广东医学,2013,34(1):68-69.
[3]Aronowski J,Zhao X.Molecular pathophysiology of cerebral hemorrhage secondary brain injury[J].Stroke,2011,42(6):1781-1786.
[4]沈雪勇.经络腧穴学[M].北京:中国中医药出版社,2008.
[5]王忠诚.神经外科学[M].武汉:湖北科学技术出版社,2005:380-381.
[6]Shukla D,Devi BI,Agrawal A.Outcome measures for traumatic brain injury[J].Clin Neurol Neurosur,2011,113(6):435-441.
[7]王玉友.康复评定[M].北京:人民卫生出版社,2000:292-293.
[8]徐如祥.脑损伤神经功能损害与修复专家共识(2016)[J/OL].中华神经创伤外科电子杂志,2016,2(2):100-104.
[9]付小兵,费舟,冯华,等.中华战创伤学·颅脑战创伤[M].郑州:郑州大学出版社,2016:409-421.
[10]陈建华,李亚新,刘影.早期针灸治疗对重型颅脑损伤患者肢体运动功能的影响[J].中国针灸,2007,27(12):907-909.
[11]Skoglund K,Hillered L,Parins K,et al.The neurological wake-up test does not alter cerebral energy metabolism and oxygenation in patients with severe traumatic brain injury[J].Neruocrit Care,2013,17(1):57-59.
[12]李丽丽.活血涤痰汤对高血压脑出血神经功能恢复的影响[J].中国实验方剂学杂志,2015,21(4):189-192.
[13]谢林均,何迪,洪芬芳,等.一氧化氮与血管老化[J].南昌大学学报(医学版),2014,54(3):70-75.
[14]季艳琴,陈莉,孙树清.大鼠实验性脑损伤血浆NO含量及NOS活性改变及意义[J].交通医学,2012,26(3):213-216.
[15]岑波,胡飞,王建一.显微外科手术治疗外伤性脑内血肿[J].临床神经外科杂志,2013,10(4):203-204.
[16]程峰,张曙光,李晓良,等.外伤性基底节区脑内血肿45例临床分析[J].临床神经外科杂志,2014,11(6):466-468.
[17]周海哲.从《金匮要略》“血不利则为水”解析张学文教授论治颅脑水瘀证[J].新中医,2015,47(4):323-324.
[18]姚军.浅谈针刺活血化瘀的理论及临床应用[J].中国针灸,2015,35(4):3:89-392.
[19]郭新荣,王瑞辉,李娜,等.针灸治疗颅脑损伤用穴规律的现代文献研究[J].时珍国医国药,2013,24(6):1433-1434.
[20]王舒,钱宇斐,樊小农,等.“水沟”穴对脑缺血模型大鼠脑神经细胞坏死的影响——从形态学角度论证经穴的特异性[J].中国针灸,2009,29(9):733-738.
[21]孙华,赵慧,张捷,等.针刺百会、足三里对抑郁症患者血清炎性细胞因子水平的影响[J].中国针灸,2010,30(3):195-199.
[22]冀雨芳,杨丽珍.针刺对颅脑损伤昏迷大鼠NE和NO表达的影响及促醒作用机理初探[J].山西中医学院学报,2015,16(3):24-26.
[23]刘旭,杨衍宁,刘忠伦,等.针药结合治疗脑出血及对S100B蛋白、神经肽?和脑水肿的影响[J].中国实验方剂学杂志,2012,18(10):295-297.