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

doi:10.3877/cma.j.issn.2095-9141.2024.02.003

Abstract

Abstract:

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

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]. Chinese Journal of Neurotraumatic Surgery(Electronic Edition), 2024, 10(02): 78-83.

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References 26

[1]	Gao G, Wu X, Feng J, et al. Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational study[J]. Lancet Neurol, 2020, 19(8): 670-677. DOI: 10.1016/S1474-4422(20)30182-4.
[2]	杨艺,王凯,周锋,等.中国三个大城市意识障碍患者的治疗及陪护者现状的多中心调查[J].临床神经外科杂志, 2017, 14(2): 102-106, 111. DOI: 10.3969/j.issn.1672-7770.2017.02.006.
[3]	中国医师协会神经修复专业委员会意识障碍与促醒学组.慢性意识障碍诊断与治疗中国专家共识[J].中华神经医学杂志, 2020, 19(10): 977-982. DOI: 10.3760/cma.j.cn115354-20200701-00525.
[4]	Latronico N, Piva S, Fagoni N, et al. Impact of a posttraumatic cerebral infarction on outcome in patients with TBI: the Italian multicenter cohort INCEPT study[J]. Crit Care, 2020, 24(1): 33. DOI: 10.1186/s13054-020-2746-5.
[5]	Giacino JT, Katz DI, Schiff ND, et al. Practice guideline update recommendations summary: disorders of consciousness: report of the guideline development, dissemination, and implementation subcommittee of American Academy of Neurology; the American Congress of Rehabilitation Medicine; and the National Institute on Disability, Independent Living, and Rehabilitation Research[J]. Arch Phys Med Rehabil, 2018, 99(9): 1699-1709. DOI: 10.1016/j.apmr.2018.07.001.
[6]	胡海成,王如海.高血压脑出血术后慢性脑积水的危险因素及预测指标分析[J].中华脑科疾病与康复杂志(电子版), 2019, 9(6): 350-354. DOI: 10.3877/cma.j.issn.2095-123X.2019.06.007.
[7]	Podell JE, Miller SS, Jaffa MN, et al. Admission features associated with paroxysmal sympathetic hyperactivity after traumatic brain injury: a case-control study[J]. Crit Care Med, 2021, 49(10): e989-e1000. DOI: 10.1097/ccm.0000000000005076.
[8]	Blackman JA, Patrick PD, Buck ML, et al. Paroxysmal autonomic instability with dystonia after brain injury[J]. Arch Neurol, 2004, 61(3): 321-328. DOI: 10.1001/archneur.61.3.321.
[9]	杨艺,党圆圆,徐珑,等.弥漫性轴索损伤致慢性意识障碍患者意识恢复的影响因素分析[J].中华神经外科杂志, 2020, 36(10): 998-1003. DOI: 10.3760/cma.j.cn112050-20200330-00176.
[10]	Tian R, Liu W, Dong J, et al. Prognostic predictors of early outcomes and discharge status of patients undergoing decompressive craniectomy after severe traumatic brain injury[J]. World Neurosurg, 2019, 126: e101-e108. DOI: 10.1016/j.wneu.2019.01.246.
[11]	Algethamy H. Baseline predictors of survival, neurological recovery, cognitive function, neuropsychiatric outcomes, and return to work in patients after a severe traumatic brain injury: an updated review[J]. Mater Sociomed, 2020, 32(2): 148-157. DOI: 10.5455/msm.2020.32.148-157.
[12]	Mollayeva T, Xiong C, Hanafy S, et al. Comorbidity and outcomes in traumatic brain injury: protocol for a systematic review on functional status and risk of death[J]. BMJ Open, 2017, 7(10): e018626. DOI: 10.1136/bmjopen-2017-018626.
[13]	Zhou JK, Zhang QS, Chen YQ, et al. Use of hematocrit for short-term prognosis of patients with traumatic brain injury after decompressive craniectomy[J]. World Neurosurg, 2019, 123: e141-e146. DOI: 10.1016/j.wneu.2018.11.095.
[14]	Su TM, Lan CM, Lee TH, et al. Posttraumatic cerebral infarction after decompressive craniectomy for traumatic brain injury: incidence, risk factors and outcome[J]. Turk Neurosurg, 2017. Online ahead of print. DOI: 10.5137/1019-5149.Jtn.20761-17.1.
[15]	Chen ZL, Li Q, Yang JY, et al. The prevalence and risk factors of posttraumatic cerebral infarction in patients with traumatic brain injury: a systematic review and meta-analysis[J]. Bioengineered, 2022, 13(5): 11706-11717. DOI: 10.1080/21655979.2022.2070999.
[16]	黄贤键,马宇强,高杰,等.创伤性大面积脑梗死的相关危险因素分析[J].中华神经创伤外科电子杂志, 2016, 2(3): 144-147. DOI: 10.3877/cma.j.issn.2095-9141.2016.03.005.
[17]	Scott RA, Rabinstein AA. Paroxysmal sympathetic hyperactivity[J]. Semin Neurol, 2020, 40(5): 485-491. DOI: 10.1055/s-0040-1713845.
[18]	Compton E. Paroxysmal sympathetic hyperactivity syndrome following traumatic brain injury[J]. Nurs Clin North Am, 2018, 53(3): 459-467. DOI: 10.1016/j.cnur.2018.05.003.
[19]	林清,谢秋幼,何艳斌,等.脑损伤后意识障碍患者意识恢复影响因素的Logistic回归分析[J].南方医科大学学报, 2017, 37(3): 337-341. DOI: 10.3969/j.issn.1673-4254.2017.03.10.
[20]	陈炎,林清,郭叶群,等.慢性意识障碍并发阵发性交感神经过度兴奋综合征的危险因素及其对预后的影响[J].临床神经病学杂志, 2019, 32(5): 359-363. DOI: 10.3969/j.issn.1004-1648.2019.05.019.
[21]	杨艺,宋明,党圆圆,等.合并阵发性交感神经过度兴奋综合征的意识障碍患者脑部结构特征的研究[J].临床神经外科杂志, 2020, 17(1): 16-21. DOI: 10.3969/j.issn.1672-7770.2020.01.005.
[22]	董月青,张赛,郎胜坤,等.慢性意识障碍合并脑积水的临床特征与疗效分析[J].临床神经外科杂志, 2020, 17(1): 27-32. DOI: 10.3969/j.issn.1672-7770.2020.01.007.
[23]	Bodien YG, Barra A, Temkin NR, et al. Diagnosing level of consciousness: the limits of the Glasgow Coma Scale total score[J]. J Neurotrauma, 2021, 38(23): 3295-3305. DOI: 10.1089/neu.2021.0199.
[24]	Huang L, Kang J, Zhong Y, et al. A predictive model for awakening in patients with prolonged disorders of consciousness after craniocerebral injury[J]. Medicine (Baltimore), 2024, 103(2): e36701. DOI: 10.1097/MD.0000000000036701.
[25]	Kang J, Zhong Y, Chen G, et al. Development and validation of a website to guide decision-making for disorders of consciousness[J]. Front Aging Neurosci, 2022, 14: 934283. DOI: 10.3389/fnagi.2022.934283.
[26]	Gritti P, Zangari R, Carobbio A, et al. Acute and subacute outcome predictors in moderate and severe traumatic brain injury: a retrospective monocentric study[J]. World Neurosurg, 2019, 128: e531-e540. DOI: 10.1016/j.wneu.2019.04.190.

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

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

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

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

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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