摘要：

目的: 探究特重型颅脑创伤患者预后不良的影响因素。方法: 共纳入2012年1月至2017年6月联勤保障部队第九○九医院暨厦门大学附属东南医院收治的133例特重型颅脑创伤[Glasgow昏迷量表（GCS）评分3~5分]患者，均行开颅血肿清除术以及标准大骨瓣减压术、超大骨瓣减压术及二者联合内减压术，术后6个月采用Glasgow预后分级（GOS）评价预后，采用单因素和多因素Logistic回归分析筛查特重型颅脑创伤患者预后不良影响因素。结果: 共133例患者根据术后6个月GOS评分分为预后良好组（GOS评分≥ 4分，12例）和预后不良组（GOS评分 < 4分，121例），预后不良组术前双侧瞳孔散大比例（P=0.000）、术中低血压比例（P=0.002）、入院时和术后颅内压（P=0.031，0.000）、术后高糖高渗状态比例（P=0.001）高于预后良好组，单纯硬膜外血肿（P=0.003）、术前钻孔引流后和术后瞳孔回缩（P=0.011，0.002）比例低于预后良好组，两组手术方式（P=0.000）和术后继发外伤性脑梗死比例（P=0.000）差异亦有统计学意义。Logistic回归分析显示，双侧瞳孔散大（OR=1.779，95% CI：1.698~4.531；P=0.004），术后高颅压（OR=12.629，95% CI：2.313~68.949；P=0.007）和术后继发外伤性脑梗死体积> 75 ml（OR=2.147，95% CI：1.894~5.156；P=0.009）是特重型颅脑创伤患者预后不良的危险因素，单纯硬膜外血肿是预后良好的保护因素（OR=0.172，95% CI：0.032~0.915；P=0.002）。结论: 单纯以GCS评分预测特重型颅脑创伤患者预后并不可靠。特重型颅脑创伤患者术前双侧瞳孔散大、术后持续颅内高压、术后继发外伤性大面积脑梗死预示预后不良，而单纯硬膜外血肿则预示预后较好。

关键词: 脑损伤, 创伤性, 格拉斯哥昏迷量表, 预后, Logistic模型

Abstract:

Objective: To screen the influencing factors for the poor prognosis in patients with ultra- severe traumatic brain injury (TBI). Methods: Total 133 patients with ultra - severe TBI [Glasgow Coma Scale (GCS) score 3-5] which admitted to the 909th Hospital of Joint Logistic Support Force; Dongnan Hospital of Xiamen University from January 2012 to June 2017 were included. All cases underwent hematoma removal with either standard craniotomy decompression or oversized craniotomy decompression, even combined with internal decompression. Glasgow Outcome Scale (GOS) was used to evaluate prognosis 6 months after surgery. Univariate and multivariate Logistic regression analyses were adopted to screen the influencing factors for poor prognosis in patients with ultra -severe TBI. Results: Total 133 patients were divided into favourable prognosis group (GOS score ≥ 4, n = 12) and poor prognosis group (GOS score < 4, n = 121). Logistic regression analysis showed bilateral pupils dilated (OR= 1.779, 95%CI: 1.698-4.531; P= 0.004), postoperative high intracranial pressure (ICP; OR= 12.629, 95%CI: 2.313-68.949, P= 0.007) and volume of secondly cerebral infarction > 75 ml (OR= 2.147, 95%CI: 1.894-5.156; P= 0.009) were the risk factors for poor prognosis, while injury subtyping of isolated epidural hematoma was the protective factor for favourable prognosis (OR= 0.172, 95%CI: 0.032-0.915; P= 0.002). Conclusions: GCS score is not reliable in solely predicting the prognosis of patients with ultra - severe TBI. Preoperative bilateral pupil dilation, postoperative high ICP and volume of secondly cerebral infarction > 75 ml were risk factors for poor prognosis of patients with ultra - severe TBI, while injury subtyping of isolated epidural hematoma was the protective factor for favourable prognosis.

Key words: Brain injuries, traumatic, Glasgow coma scale, Prognosis, Logistic models