高原地区颅脑创伤患者术后血肿扩大的危险因素及预后分析

Analysis of risk factors and prognosis of postoperative hematoma enlargement in patients with craniocerebral trauma in plateau areas

目的探讨高原地区颅脑创伤患者术后血肿扩大的危险因素并分析其预后情况.方法回顾性分析2019年5月至2023年1月云南省滇南中心医院神经外科(331例)和陆军第九五六医院神经外科(22例)收治的353例高原地区颅脑创伤后行手术治疗的患者的临床资料.根据术后3 d内CT检查结果显示的血肿量变化情况,将其分为血肿扩大组与血肿未扩大组.收集患者的临床资料,包括有无颅内多发血肿、侧裂出血、颅骨骨折、中线移位、血清血红蛋白水平、入院血压、入院格拉斯哥昏迷评分(GCS)、血清血小板计数、合并的基础疾病、血糖水平等情况,采用单因素分析和多因素logistic回归模型探讨可能影响颅脑创伤患者术后血肿扩大的因素.出院时采用改良格拉斯哥预后评分(GOS)评估患者的预后,并比较两组患者的恢复良好(GOS≥4分)比率.绘制Kaplan-Meier生存曲线,采用log-rank检验比较两组出院时的预后.结果353例患者中,血肿扩大组34例(9.63%),血肿未扩大组319例(90.37%).与血肿未扩大组相比,血肿扩大组存在侧裂出血和颅内多发血肿患者的比例更高、入院时GCS更低、中线移位距离更大、收缩压更高(均P<0.05);而两组性别、年龄、民族、是否合并基础疾病、有无颅骨骨折、是否合并硬膜外血肿、血清血小板计数、血糖、血红蛋白、舒张压的差异均无统计学意义(均P>0.05).多因素logistic回归模型分析结果提示,中线移位明显(OR=0.34,95%CI:0.17~0.68,P=0.002)、存在侧裂出血(OR=2.16,95%CI:1.06~4.41,P=0.035)、有颅内多发血肿(OR=4.72,95%CI:2.21~10.05,P<0.001)、入院GCS较低(OR=1.20,95%CI:1.09~1.33,P<0.001)和入院收缩压偏高(OR=0.99,95%CI:0.98~1.00,P=0.030)均为高原地区颅脑创伤患者术后血肿扩大的危险因素;血肿扩大组患者的恢复良好比率明显低于血肿未扩大组[32.35%(11/34)对比71.16%(227/319),χ^(2)=21.07,P<0.001].住院时长[M(Q_(1),Q_(3))]为17(10,24)do Log-rank分析结果显示,两组生存率的差异无统计学意义(P>0.05).结论存在侧裂出血或颅内多发血肿、中线移位明显、入院GCS低和入院收缩压高的高原颅脑创伤患者术后更易出现血肿扩大,且血肿扩大患者的短期预后较差.

Objective To explore the risk factors for postoperative hematoma enlargement in patients with craniocerebral trauma in plateau areas and to analyze their outcomes.Methods A retrospective analysis was performed on the clinical data of 353 patients of craniocerebral trauma in plateau areas who were admitted to the Department of Neurosurgery of Southern Central Hospital of Yunnan Province(331 cases)and the Department of Neurosurgery of the PLA 956th Hospital(22 cases)and underwent surgical treatment from May 2019 to January 2023.According to the changes in hematoma volume shown in the CT examination results within 3 days after surgery,the patients were divided into a hematoma enlargement group and a hematoma non-enlargement group.The clinical data of the patients were collected,including whether there were multiple intracranial hematomas,Sylvian hemorrhage,skull fractures,midline shifts,serum hemoglobin levels,admission blood pressure,admission Glasgow Coma Scale(GCS),serum platelet count,combined underlying diseases,and blood glucose level and other conditions.Univariate analysis and multivariate logistic regression model were used to explore the factors that may affect the expansion of postoperative hematoma in patients with craniocerebral trauma.The modified Glasgow Outcome Score(GOS)was used to evaluate the patient's outcome at discharge,and the rate of good recovery(GOS≥4 points)between the two groups was compared.Kaplan-Meier survival curves were drawn,and the outcome at discharge between the two groups was compared using the log-rank test.Results Among the 353 patients,34(9.63%)were in the hematoma enlargement group and 319(90.37%)were in the hematoma non-enlargement group.Compared with the hematoma non-enlargement group,the hematoma enlargement group had a higher proportion of patients with Sylvian hemorrhage and multiple intracranial hematomas,lower GCS on admission,greater midline shift distance,and higher systolic blood pressure(all P<0.05).However,there were no statistically significant differences in gender,age,nationality,whether there were underlying diseases,skull fracture,epidural hematoma,serum platelet count,blood glucose level,hemoglobin,or diastolic blood pressure(all P>0.05).The results of multivariate logistic regression model analysis showed that there was significant midline shift(OR=0.34,95%CI:0.17-0.68,P=0.002)and the presence of Sylvian hemorrhage(OR=2.16,95%CI:1.06-4.41,P=0.035),multiple intracranial hematomas(OR=4.72,95%CI:2.21-10.05,P<0.001),lower admission GCS(OR=1.20,95%CI:1.09-1.33,P<0.001)and high systolic blood pressure at admission(OR=0.99,95%CI:0.98-1.00,P=0.030)were risk factors for postoperative hematoma enlargement in patients with craniocerebral trauma in plateau areas.The rate of good recovery in the hematoma enlargement group was significantly lower than that in the hematoma non-enlargement group[32.35%(11/34)vs.71.16%(227/319),χ^(2)=21.07,P<0.001].The length of hospitalization[M(Q_(1),Q_(3))]was 17(10,24)days.Log-rank analysis results showed that the difference in survival rates between the two groups was not statistically significant(P>0.05).Conclusions Patients with craniocerebral trauma in plateau areas who have Sylvian hemorrhage or multiple intracranial hematomas,significant midline shift,low admission GCS,and high admission systolic blood pressure are more likely to have hematoma enlargement after surgery.The short-term prognosis of patients with hematoma enlargement is poor.