Perel Pablo, Roberts Ian, Bouamra Omar, Woodford Maralyn, Mooney Jane, Lecky Fiona
Epidemiology and Population Health Department, London School of Hygiene & Tropical Medicine, London, UK.
BMC Emerg Med. 2009 Aug 3;9:15. doi: 10.1186/1471-227X-9-15.
Intracranial bleeding (IB) is a common and serious consequence of traumatic brain injury (TBI). IB can be classified according to the location into: epidural haemorrhage (EDH) subdural haemorrhage (SDH) intraparenchymal haemorrhage (IPH) and subarachnoid haemorrhage (SAH). Studies involving repeated CT scanning of TBI patients have found that IB can develop or expand in the 48 hours after injury. If IB enlarges after hospital admission and larger bleeds have a worse prognosis, this would provide a therapeutic rationale for treatments to prevent increase in the extent of bleeding. We analysed data from the Trauma Audit & Research Network (TARN), a large European trauma registry, to evaluate the association between the size of IB and mortality in patients with TBI.
We analysed 13,962 patients presenting to TARN participating hospitals between 2001 and 2008 with a Glasgow Coma Score (GCS) less than 15 at presentation or any head injury with Abbreviated Injury Scale (AIS) severity code 3 and above. The extent of intracranial bleeding was determined by the AIS code. Potential confounders were age, presenting Glasgow Coma Score, mechanism of injury, presence and nature of other brain injuries, and presence of extra-cranial injuries. The outcomes were in-hospital mortality and haematoma evacuation. We conducted a multivariable logistic regression analysis to evaluate the independent effect of large and small size of IB, in comparison with no bleeding, on patient outcomes. We also conducted a multivariable logistic regression analysis to assess the independent effect on mortality of large IB in comparison with small IB.
Almost 46% of patients had at some type of IB. Subdural haemorrhages were present in 30% of the patients, with epidural and intraparenchymal present in approximately 22% each. After adjusting for potential confounders, we found that large IB, wherever located, was associated with increased mortality in comparison with no bleeding. We also found that large IB was associated with an increased risk of mortality in comparison with small IB. The odds ratio for mortality for large SDH, IPH and EDH, in comparison with small bleeds, were: 3.41 (95% CI: 2.684.33), 3.47 (95% CI: 2.265.33) and 2.86 (95% CI: 1.864.38) respectively.
Large EDH, SDH and IPH are associated with a substantially higher probability of hospital mortality in comparison with small IB. However, the limitations of our data, such as the large proportion of missing data and lack of data on other confounding factors, such as localization of the bleeding, make the results of this report only explanatory. Future studies should also evaluate the effect of IB size on functional outcomes.
颅内出血（IB）是创伤性脑损伤（TBI）常见且严重的后果。IB可根据部位分为：硬膜外出血（EDH）、硬膜下出血（SDH）、脑实质内出血（IPH）和蛛网膜下腔出血（SAH）。对TBI患者进行重复CT扫描的研究发现，IB可在受伤后48小时内形成或扩大。如果入院后IB增大，且较大出血的预后更差，这将为预防出血范围扩大的治疗提供理论依据。我们分析了来自欧洲大型创伤登记处创伤审计与研究网络（TARN）的数据，以评估TBI患者中IB大小与死亡率之间的关联。
我们分析了2001年至2008年间在TARN参与医院就诊的13962例患者，这些患者就诊时格拉斯哥昏迷评分（GCS）低于15分，或有任何头部损伤且简明损伤定级标准（AIS）严重程度代码为3及以上。颅内出血的程度由AIS代码确定。潜在混杂因素包括年龄、就诊时的格拉斯哥昏迷评分、损伤机制、其他脑损伤的存在及性质，以及颅外损伤的存在。结局指标为住院死亡率和血肿清除情况。我们进行了多变量逻辑回归分析，以评估与无出血相比，大、小IB对患者结局的独立影响。我们还进行了多变量逻辑回归分析，以评估与小IB相比，大IB对死亡率的独立影响。
近46%的患者有某种类型的IB。30%的患者有硬膜下出血，硬膜外和脑实质内出血各约占22%。在对潜在混杂因素进行调整后，我们发现，与无出血相比，无论位于何处的大IB均与死亡率增加相关。我们还发现，与小IB相比，大IB与死亡风险增加相关。与小出血相比，大SDH、IPH和EDH的死亡比值比分别为：3.41（95%CI：2.68 - 4.33）、3.47（95%CI：2.26 - 5.33）和2.86（95%CI：1.86 - 4.38）。
与小IB相比，大EDH、SDH和IPH与医院死亡率显著更高的可能性相关。然而，我们数据的局限性，如大量缺失数据以及缺乏关于其他混杂因素（如出血部位）的数据，使得本报告的结果仅具有解释性。未来的研究还应评估IB大小对功能结局的影响。
