非急诊开颅手术的创伤性脑实质挫伤及血肿患者发生进展的危险因素分析

Analysis of risk factors for traumatic intraparenchymal contusions and hematomas progression in patients with non-emergency craniotomy

目的观察单纯创伤性脑实质挫伤及血肿(TIPHs)患者发生进展的自然进程,并分析影响其进展的危险因素。方法采用前瞻性研究的方法,选取南方医科大学附属小榄医院2018年7月至2020年1月TIPHs患者69例,记录患者的性别、年龄、受伤原因、复合伤情况、格拉斯哥昏迷评分(GCS),于入院时检测血浆凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(Fbg)、国际化标准值(INR)、D-二聚体、血小板、血红蛋白,观察低氧血症和高颅内压发生情况。记录首次CT检查时间、首次CT血肿体积、对照CT检查时间、对照CT血肿体积,及首次CT检查的病灶形态、多发灶、蛛网膜下隙出血(SAH)、水肿带、皮质距离,分析影响TIPHs患者发生进展的危险因素。结果69例TIPHs中,28例发生TIPHs进展(进展组),进展率为40.58%;未发生血肿进展41例(未进展组)。两组性别构成、年龄、PT、APTT、INR、血红蛋白、受伤原因、合并伤、低氧血症发生率、高颅内压发生率、SAH发生率、水肿带发生率、病灶不规则率、首次CT检查时间、对照CT检查时间、首次CT血肿体积比较差异无统计学意义(P>0.05)。进展组GCS、皮质距离、Fbg明显低于非进展组,TT、血小板、多发灶率、对照CT血肿体积明显高于非进展组,差异有统计学意义(P<0.01或<0.05)。多因素Logistic回归分析结果显示,皮质距离<1 cm、Fbg<2 g/L和多发灶是影响TIPHs患者发生进展的独立危险因素(OR=6.723、5.515、4.827,P<0.05),模型判断TIPHs患者发生进展的敏感度为71.43%(20/28),特异度为92.68%(38/41),准确率为84.06%(58/69)。结论基于TIPHs患者发生进展的危险因素,对患者进行提前预判,对高风险患者给予必要的干预措施将有利于降低进展发生率,改善预后。

Objective To observe the natural course of patients with simple traumatic intraparenchymal contusions and hematomas(TIPHs),and analyze the risk factors for TIPHs progression.Methods Using a prospective observational study,69 patients with TIPHs in Affiliated Xiaolan Hospital,Southern Medical University from July 2018 to January 2020 were selected.The gender,age,cause of injury,compound injury status,combined injury and Glasgow coma score(GCS)were recorded.The plasma levels of prothrombin time(PT),activated partial thromboplastin time(APTT),thrombin time(TT),fibrinogen(Fbg),international normalized ratio(INR),D-dimer,platelet,hemoglobin at admission were detected.The occurrence of hypoxemia and high intracranial pressure were observed.The time of the first CT examination,volume of the first CT hematoma,time of the control CT examination,volume of the control CT hematoma,and lesion morphology,multifocality,subarachnoid hemorrhage(SAH),edema zone and cortical distance showed in the first CT examination were recorded.The risk factors of progression in patients with TIPHs were analyzed.Results Among 69 patients with TIPHs,TIPHs progression was in 28 cases(progression group),and the progression rate was 40.58%;TIPHs progression was not in 41 cases(non-progression group).There were no statistical differences in gender composition,age,PT,APTT,INR,hemoglobin,cause of injury,compound injury,incidence of hypoxemia,incidence of high intracranial pressure,incidence of SAH,incidence of edema zone,incidence of irregular lesions,time of the first CT examination,time of the control CT examination and volume of the first CT hematoma between 2 groups(P>0.05).The GCS,cortical distance and Fbg in progression group were significantly lower than those in non-progression group,the TT,platelet,multifocality rate and volume of the control CT hematoma were significantly higher than those in non-progression group,and there were statistical differences(P<0.01 or<0.05).Multivariate Logistic regression analysis result showed that cortical distance<1 cm,Fbg<2 g/L and multifocality were independent risk factors affecting the progression in patients with TIPHs(OR=6.723,5.515 and 4.827;P<0.05).The model had a sensitivity of 71.43%(20/28),a specificity of 92.68%(38/41),and an accuracy of 84.06%(58/69)in judging the progression of TIPHs.Conclusions Based on the risk factors for the progression of TIPHs,predicting these patients in advance can provide necessary intervention measures for high-risk patients,which will help to reduce the rate of progression and improve the prognosis of patients.