Background: Whether the Glasgow Coma Scale (GCS) can assess intubated patients is still a topic of controversy. We compared the test performance of the GCS motor component (GCS-M)/Simplified Motor Score (SMS) to the total of the GCS in predicting the outcomes of intubated acute severe cerebral vascular disease patients.
Methods: A retrospective analysis of prospectively collected observational data was performed. Between January 2012 and October 2015, 106 consecutive acute severe cerebral vascular disease patients with intubation were included in the study. GCS, GCS-M, GCS eye-opening component, and SMS were documented on admission and at 24, 48, and 72 h after admission to Neurointensive Care Unit (NCU). Outcomes were death and unfavorable prognosis (modified Rankin Scale: 5-6) at NCU discharge. The receiver operating characteristic (ROC) curve was obtained to determine the prognostic performance and best cutoff value for each scoring system. Comparison of the area under the ROC curves (AUCs) was performed using the Z- test.
Results: Of 106 patients included in the study, 41 (38.7%) patients died, and 69 (65.1%) patients had poor prognosis when discharged from NCU. The four time points within 72 h of admission to the NCU were equivalent for each scale's predictive power, except that 0 h was the best for each scale in predicting outcomes of patients with right-hemisphere lesions. Nonsignificant difference was found between GCS-M AUCs and GCS AUCs in predicting death at 0 h (0.721 vs. 0.717, Z = 0.135, P = 0.893) and 72 h (0.730 vs. 0.765, Z = 1.887, P = 0.060), in predicting poor prognosis at 0 h (0.827 vs. 0.819, Z = 0.395, P = 0.693), 24 h (0.771 vs. 0.760, Z = 0.944, P = 0.345), 48 h (0.732 vs. 0.741, Z = 0.593, P = 0.590), and 72 h (0.775 vs. 0.780, Z = 0.302, P = 0.763). AUCs in predicting death for patients with left-hemisphere lesions ranged from 0.700 to 0.804 for GCS-M and from 0.700 to 0.824 for GCS, in predicting poor prognosis ranged from 0.841 to 0.969 for GCS-M and from 0.875 to 0.969 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). No significant difference between GCS-M AUCs and GCS AUCs was found in predicting death (0.964 vs. 0.964, P = 1.000) and poor prognosis (1.000 vs. 1.000, P = 1.000) for patients with right-hemisphere lesions at 0 h. AUCs in predicting death for patients with brainstem or cerebella were poor for GCS-M (<0.700), in predicting poor prognosis ranged from 0.727 to 0.801 for GCS-M and from 0.704 to 0.820 for GCS, with no significant difference between GCS-M AUCs and GCS AUCs within 72 h (P > 0.05). The SMS AUCs (<0.700) in predicting outcomes were poor.
Conclusions: The GCS-M approaches the same test performance as the GCS in assessing the prognosis of intubated acute severe cerebral vascular disease patients. The GCS-M could be accurately and reliably applied in patients with hemisphere lesions, but caution must be taken for patients with brainstem or cerebella lesions.
简化昏迷量表评估研究：急性脑血管病伴气管插管患者摘要背景：格拉斯哥昏迷评分（GCS）是否可用于评估气管插管患者一直存在争议。我们致力于明确简化昏迷评分是否能够取代GCS预测急性重症脑血管病伴气管插管患者预后。 方法：回顾性分析前瞻性收集的2012年1月-2015年10月收入首都医科大学宣武医院神经内科监护病房（NCU）的106例急性重症脑血管病伴气管插管患者的资料。记录每个患者入住NCU 0h、24h、48h、72h的GCS及GCS运动反应项（GCS-M）等组分、简化运动评分（SMS）。记录出院时的结局：生存/死亡和预后良好/预后不良（改良mRS 5-6分）。用受试者工作曲线下面积（ROC）表示各昏迷评分预测预后的效能并确定预测预后较为准确的界值。两个ROC曲线下面积（AUC）的比较采用Z检验。 结果：本研究纳入106例急性重症脑血管病伴气管插管患者，出NCU时41例(38.7%)死亡、69例（65.1％）预后不良。除了各昏迷评分在0h预测右侧大脑半球受损患者预后的效能最佳，各个昏迷评分在入住NCU 72小时内的预测效能无差异。0h GCS-M（0.721 vs. 0.717, z=0.135，p=0.8 93）、72h GCS-M （0.730 vs. 0.765, z=1.887，p=0.060）预测死亡的效能与GCS相当。0h GCS-M（0.827 vs 0.819, z=0.395，p=0.693），24h GCS-M（0.771 vs 0.760, z=0.944，p=0.345），48h GCS-M （0.732 vs 0.741, z=0.593，p=0.590）和72h GCS-M（0.775 vs 0.780, z=0.302，p=0.763）预测预后不良的效能与GCS相当. 亚组分析：0h GCS-M（0.700 vs 0.700, z=0.000，p=1.000），24h GCS-M（0.750 vs 0.763, z=0.684，p=0.494），48h GCS-M （0.735 vs 0.760, z=0.834，p=0.404）和72h GCS-M（0.804 vs 0. 827, z=0.725，p=0.468）预测左侧大脑半球受损患者死亡的效能与GCS无统计学差异。0h GCS-M（0.969 vs 0.969, z=0.000，p=1.000），24h GCS-M（0.958 vs 0.955, z=0.151，p=0.880），48h GCS-M （0.841 vs 0.875, z=0.922，p=0.356）和72h GCS-M（0.887 vs 0.920, z=0.846，p=0.398）预测左侧大脑半球受损患者预后不良的效能与GCS无统计学差异。0h GCS-M 预测右侧大脑半球受损患者死亡 (0.964 vs 0.964, z=0.000，p=1.000) 和预后不良(1.000 vs 1.000, z=0.000,p=1.000) 的效能与GCS无统计学差异。GCS-M预测脑干小脑受损患者死亡的效能较低 (AUCs<0.700)。 0h GCS-M（0.727 vs 0.704, z=0.831，p=0.406），24h GCS-M（0.752 vs 0.730, z=1.283，p=0.200），48h GCS-M （0.731 vs 0.753, z=0.694，p=0.488）和72h GCS-M（0.801 vs 0.820, z=0.525，p=0.599）预测脑干小脑受损预后不良的效能与GCS无统计学差异。SMS 的预测预后的效能较低(AUCs <0.700). 结论：GCS-M预测急性重症脑血管病伴气管插管患者死亡或不良预后效能与GCS相当。考虑GCS-M可用于预测左侧大脑半球和右侧大脑半球损伤患者的预后，但对小脑脑干受损患者慎用。.
Keywords: Coma Scale; Consciousness Disorders; Intubation; Prognosis.