急性颅脑损伤后进展性出血性损伤极高危因素分析及定时复查CT时间探讨

High-risk factors of progressive hemorrhagic injury after acute traumatic brain injury and its time for first scheduled brain CT

目的探讨急性创伤性颅脑损伤后进展性出血性损伤（PHI）极高危患者的影响网素及伤后首次定时复查CT的时间窗。方法对苏州大学附属第二医院神经外科自2009年6月至2010年5月收治的329例闭合性创伤性颅脑损伤住院患者的临床资料进行回顾性分析，将患者按是否于常规首次定时复查CT前出现临床症状恶化分为PHI极高危组、非PHI极高危组并进行对照研究。结果PHI极高危组41例患者出现临床症状恶化而提前复查头颅CT，时间为（3．67±0．96）h（Md=3．8h），与非PHI极高危组288例患者常规首次定时复查CT时间[（8．38±3．03）h（Md=7．6h）]比较差异有统计学意义（P〈0．05）。PHI极高危组与非PHI极高危组在首次CT颅内血肿〉10mL、颅内血肿类型≥2、合并蛛网膜下腔出血、人院时意识障碍、瞳孔扩大、GCS评分≤12分、平均动脉压增高、Pit减少、PT延长、APTT延长、FIB降低、首次CT为双侧伤、合并脑挫裂伤、骨折处硬膜外血肿上的差异有统计学意义（P〈0．05）。Logistic多元回归分析示PHI极高危患者与首次CT颅内血肿〉10mL、入院时意识障碍、瞳孔扩大密切相关（P〈0．05）。结论急性创伤性颅脑损伤患者伤后早期特别是2h内首次CT颅内血肿〉10mL或人院时存在意识障碍或瞳孔扩大，最好于颅脑损伤后3-4h甚至更早进行首次定时复查CT扫描。

Objective To investigate the high-risk factors of progressive hemohagic injury （PHI） after acute traumatic brain injury （TBI） and discuss its time for first scheduled brain CT. Methods Retrospective analysis of clinical data of 329 adult patients with blunt TBI, admitted to second affiliated hospital of Suzhou University from August 2009 to July 2010, was performed. Patients were divided into PHI high-risk group and non-PHI high-risk group based on whether clinical symptoms worsened before the first routine scheduled brain CT; and control study was established. Results Forty-one patients from the PHI high-risk group were performed first routine scheduled brain CT ahead of time （[3.67±0.96] h） for appearing worsened clinical symptoms, while 288 patients with non-PHI high-risk group were performed first routine brain CT as schedule （8.38±3.03 h）; significant difference on the time for the first brain CT was noted between the 2 groups （P〈0.05）. Statistical differences in aspects c,f intracranial hematoma volume〉1 0 mL, intracranial hematoma type t〉 2, associated subarachnoid hemorrhage on initial brain CT, disturbance of consciousness, pupil dilation and scores of Glasgow Coma Scale P〈 12 on admission were noted between the 2 groups （P〈0.05）, and statistical differences in aspects of reduced platelet （Plt）, prolonged prothrombin time （PT）, prolonged activated partial thromboplastin lime （APTT）, decreased Fibrinogen （FIB） on admission, bilateral brain injury, associated brain contusion, and skull fracture with epidural hematoma on initial brain CT were found between the 2 groups （P〈0.05）. Logistic regression analysis showed that intracranial hematoma volume〉10 mL on initial brain CT, disturbance of consciousness and pupil dilation on admission were predictors for PHI high-risk patients （P〈0.05）. Conclusion For patients with intracranial hematoma volume〉10 mL on initial brain CT, disturbance of consciousness and pupil dilation on admission within 2 h of TBI, first routine scheduled brain CT should be performed within 3-4 h of TBI or even earlier.