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中华神经创伤外科电子杂志 ›› 2024, Vol. 10 ›› Issue (02) : 78 -83. doi: 10.3877/cma.j.issn.2095-9141.2024.02.003

临床研究

重型创伤性脑损伤患者术后慢性意识障碍的危险因素及其预测价值
王如海1, 韩超1, 于强1, 胡海成1,†(), 孙菲琳1, 杨震1   
  1. 1. 236063　阜阳，阜阳师范大学附属第二医院（阜阳市第五人民医院）神经外科
  • 收稿日期:2023-03-15 出版日期:2024-04-15
  • 通信作者: 胡海成

Risk factors and predictive value of postoperative prolonged disorders of consciousness in patients with severe traumatic brain injury

Ruhai Wang1, Chao Han1, Qiang Yu1, Haicheng Hu1,†(), Feilin Sun1, Zhen Yang1   

  1. 1. Department of Neurosurgery, The Second Affiliated Hospital of Fuyang Normal University (Fuyang Fifth People's Hospital), Fuyang 236063, China
  • Received:2023-03-15 Published:2024-04-15
  • Corresponding author: Haicheng Hu
  • Supported by:
    Foundation of Fuyang Health Commission(FY2021-081, FY2023-019)
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引用本文：

王如海, 韩超, 于强, 胡海成, 孙菲琳, 杨震. 重型创伤性脑损伤患者术后慢性意识障碍的危险因素及其预测价值[J/OL]. 中华神经创伤外科电子杂志, 2024, 10(02): 78-83.

Ruhai Wang, Chao Han, Qiang Yu, Haicheng Hu, Feilin Sun, Zhen Yang. Risk factors and predictive value of postoperative prolonged disorders of consciousness in patients with severe traumatic brain injury[J/OL]. Chinese Journal of Neurotraumatic Surgery(Electronic Edition), 2024, 10(02): 78-83.

目的

探讨重型创伤性脑损伤（sTBI）患者术后慢性意识障碍（pDoC）的危险因素及其预测价值。

方法

回顾性分析阜阳师范大学附属第二医院神经外科自2018年1月至2022年12月收治的179例手术治疗的sTBI患者的临床资料，根据术后昏迷时间是否超过28 d，将患者分为pDoC组（≥28 d）和非pDoC组（<28 d）。采用单因素及多因素Logistic回归分析，揭示sTBI患者术后pDoC形成的危险因素，采用受试者工作特征（ROC）曲线分析危险因素对pDoC的预测价值。

结果

179例sTBI患者中，60例发生pDoC，发生率为33.5%。pDoC组与非pDoC组的年龄、脑疝、创伤性脑室出血、GCS评分、去骨瓣减压、术后并发症[创伤性脑梗死（PTCI）、创伤性硬膜下积液、应激性溃疡、阵发性交感神经过度兴奋综合征（PSH）、慢性脑积水（HCP）]比较，差异有统计学意义（P<0.05）。多因素Logistic回归分析显示，年龄（OR=1.087，95%CI：1.039~1.138，P<0.001）、GCS评分（OR=0.664，95%CI：0.450~0.980，P=0.039）、PTCI（OR=0.049，95%CI：0.004~0.581，P=0.017）、PSH(OR=0.006，95%CI：0.000~0.104，P<0.001)、慢性HCP（OR=0.083，95%CI：0.011~0.604，P=0.014）是pDoC形成的独立危险因素。年龄、GCS评分、PTCI、PSH及慢性HCP预测pDoC的曲线下面积（AUC）分别为0.597（截断值为69岁）、0.824（截断值为5分）、0.612、0.642、0.667，联合预测发生pDoC的AUC为0.938（95%CI：0.892~0.969，P<0.001）。

结论

高龄（>69岁）、GCS评分低（≤5分）、PTCI、PSH、慢性HCP是sTBI患者术后发生pDoC的独立危险因素，联合应用对pDoC的发生具有较好的预测价值。

关键词: 重型创伤性脑损伤, 慢性意识障碍, 危险因素, 预测, 神经外科手术
Objective

To investigate the risk factors of postoperative prolonged disorders of consciousness (pDoC) in patients with severe traumatic brain injury (sTBI) and to analyze their predictive value.

Methods

Clinical data of 179 patients with sTBI underwent surgery admitted to Neurosurgery Department of The Second Affiliated Hospital of Fuyang Normal University from January 2018 to December 2022 were retrospectively analyzed. The patients were divided into the group of pDoC (≥28 d) and the group of non-pDoC (<28 d), according to whether the duration of coma was at least 28 d after sugery. Univariate and multivariate binary Logistic regression analysis were applied to analyze the independent risk factors for pDoC. The receiver operating characteristic (ROC) curve was used to investigate the predictive value of the risk factors for pDoC.

Results

Of these 179 patients with sTBI, 60 patients suffered from pDoC, and the incidence rate was 33.5%. Age, cerebral herniation, traumatic ventricular hemorrhage, GCS score, decompressive craniectomy, postoperative complications [traumatic cerebral infarction (PTCI), traumatic subdural effusion, stress ulcers, paroxysmal sympathetic hyperactivity (PSH), and chronic hydrocephalus (HCP)] were compared between the pDoC group and the non-pDoC group, and the differences were statistically significant (P<0.05). Multivariate binary Logistic regression analysis showed that age (OR =1.087, 95%CI: 1.039-1.138, P<0.001), GCS score (OR=0.664, 95%CI: 0.450-0.980, P=0.039), PTCI (OR=0.049, 95%CI: 0.004-0.581, P=0.017), PSH (OR=0.006, 95%CI: 0.000-0.104, P<0.001), chronic HCP (OR=0.083, 95%CI: 0.011-0.604, P=0.014) were independent risk factors for the formation of pDoC. The areas under the curve (AUC) of those independent risk factors were 0.597 (69 years as the threshold for age) and 0.824 (5 points as the threshold for GCS), 0.612, 0.642 and 0.667, respectively. The AUC of the risk factors combined to predict pDoC was 0.938 (95%CI: 0.892-0.969, P<0.001).

Conclusion

Age (>69 years), GCS score (≤5 points), PTCI, PSH and chronic HCP are independent risk factors for pDoC. Those indexes could be jointly applied to improve the predictive value for pDoC.

Key words: Severe traumatic brain injury, Prolonged disorders of consciousness, Risk factors, Forecasting, Neurosurgical procedures
表1 2组患者的临床资料比较
Tab.1 Comparison of clinical data between two groups
项目 pDoC组（n=60） 非pDoC组（n=119） χ2/t值 P值
男性[例（%）] 43（71.7） 83（69.7） 0.791 0.070
年龄（岁，±s） 58.6±17.3 53.6±14.4 2.048 0.042
受伤原因[例（%）]     1.889 0.389
车祸 32（53.3） 51（42.9）    
跌伤 22（36.7） 51（42.9）    
其他 6（10.0） 17（14.3）    
高血压[例（%）] 12（20.0） 19（16.0） 0.501 0.453
糖尿病[例（%）] 6（10.0） 9（7.6） 0.309 0.579
脑疝[例（%）] 44（73.3） 43（36.1） 22.096 <0.001
颅底骨折[例（%）] 29（48.3） 45（37.8） 1.820 0.177
创伤性脑室出血[例（%）] 9（15.0） 6（5.0） 5.152 0.023
GCS评分（分，±s） 4.7±1.7 7.0±1.4 -8.818 <0.001
去骨瓣减压[例（%）] 50（83.3） 32（26.9） 51.189 <0.001
术后并发症[例（%）]        
PTCI 14（23.3） 1（0.8） 26.285 <0.001
创伤性硬膜下积液 16（26.7） 11（9.2） 9.453 0.002
应激性溃疡 41（68.3） 25（21.0） 38.380 <0.001
PSH 18（30.0） 2（1.7） 32.232 <0.001
慢性HCP 22（36.7） 4（3.4） 35.638 <0.001
表2 sTBI患者术后pDoC形成的多因素Logistic回归分析
Tab.2 Multivariate Logistic regression analysis of postoperative pDoC in sTBI patients
因素 回归系数 标准误 Wald's χ2值 OR值 95%CI P值
年龄 0.084 0.023 13.002 1.087 1.039~1.138 <0.001
脑疝 -0.311 0.727 0.183 0.733 0.176~3.045 0.669
创伤性脑室出血 0.163 0.854 0.036 1.177 0.221~6.274 0.849
GCS评分 -0.410 0.198 4.260 0.664 0.450~0.980 0.039
去骨瓣减压 -1.099 0.656 2.810 0.333 0.092~1.204 0.094
PTCI -3.025 1.267 5.705 0.049 0.004~0.581 0.017
应激性溃疡 -0.835 0.544 2.360 0.434 0.150~1.259 0.125
PSH -5.081 1.436 12.523 0.006 0.000~0.104 <0.001
慢性HCP -2.494 1.016 6.030 0.083 0.011~0.604 0.014
创伤性硬膜下积液 1.021 0.981 1.083 2.772 0.406~18.974 0.298
图1 不同危险因素预测pDoC的受试者工作特征曲线
Fig.1 Receiver operating characteristic curve of different risk factors predicting pDoC
表3 危险因素预测pDoC的曲线下面积
Tab.3 Area under the curve of pDoC predicted by risk factors
因素 曲线下面积 截断值 灵敏度（%） 特异度（%） 95%CI P值
年龄 0.597 69岁 35.00 85.71 0.521~0.669 0.041
GCS评分 0.824 5分 76.67 83.19 0.761~0.877 <0.001
PTCI 0.612 - 23.33 99.16 0.537~0.684 0.017
PSH 0.642 - 30.00 98.32 0.567~0.712 0.003
慢性HCP 0.667 - 36.67 96.64 0.592~0.735 <0.001
所有指标联合预测 0.938 - 75.00 90.76 0.892~0.969 <0.001
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