Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands.
Neurosurgery. 2012 Apr;70(4):811-8; discussion 818. doi: 10.1227/NEU.0b013e318235d640.
Major extracranial injury (MEI) is common in traumatic brain injury (TBI) patients, but the effect on outcome is controversial.
To assess the prognostic value of MEI on mortality after TBI in an individual patient data meta-analysis of 3 observational TBI studies (International Mission on Prognosis and Clinical Trial Design in TBI [IMPACT]), a randomized controlled trial (Corticosteroid Randomization After Significant Head Injury [CRASH]), and a trauma registry (Trauma Audit and Research Network [TARN]).
MEI (extracranial injury with an Abbreviated Injury Scale ≥ 3 or requiring hospital admission) was related to mortality with logistic regression analysis, adjusted for age, Glasgow Coma Scale motor score, and pupil reactivity and stratified by TBI severity. We pooled odds ratios (ORs) with random-effects meta-analysis.
We included 39,274 patients. Mortality was 25%, and 32% had MEI. MEI was a strong predictor for mortality in TARN, with adjusted odds ratios of 2.81 (95% confidence interval [CI], 2.44-3.23) in mild, 2.18 (95% CI, 1.80-2.65) in moderate, and 2.14 (95% CI, 1.95-2.35) in severe TBI patients. The prognostic effect was smaller in IMPACT and CRASH, with pooled adjusted odds ratios of 2.14 (95% CI, 0.93-4.91) in mild, 1.46 (95% CI, 1.14-1.85) in moderate, and 1.18 (95% CI, 1.03-1.55) in severe TBI. When patients who died within 6 hours after injury were excluded from TARN, the effect of MEI was comparable with IMPACT and CRASH.
MEI is an important prognostic factor for mortality in TBI patients. However, the effect varies by population, which explains the controversy in the literature. The strength of the effect is smaller in patients with more severe brain injury and depends on time of inclusion in a study.
在外伤性脑损伤（TBI）患者中，常见主要的颅外损伤（MEI），但其对预后的影响存在争议。
通过对 3 项观察性 TBI 研究（国际 TBI 预后和临床试验设计研究[IMPACT]）、一项随机对照试验（颅脑损伤后皮质类固醇随机化[CRASH]）和一个创伤登记处（创伤审核和研究网络[TARN]）的个体患者数据进行荟萃分析，评估 MEI 对 TBI 患者死亡率的预后价值。
采用逻辑回归分析，将 MEI（损伤程度评分≥3 或需要住院治疗的颅外损伤）与死亡率相关联，并按 TBI 严重程度进行分层，同时调整年龄、格拉斯哥昏迷量表运动评分和瞳孔反应。我们采用随机效应荟萃分析来汇总优势比（ORs）。
我们纳入了 39274 名患者。死亡率为 25%，32%的患者发生了 MEI。MEI 是 TARN 患者死亡率的一个强有力的预测因素，轻度 TBI 患者调整后的 OR 为 2.81（95%可信区间[CI]，2.44-3.23），中度 TBI 患者为 2.18（95% CI，1.80-2.65），重度 TBI 患者为 2.14（95% CI，1.95-2.35）。IMPACT 和 CRASH 的预后效果较小，轻度 TBI 患者调整后的 OR 为 2.14（95% CI，0.93-4.91），中度 TBI 患者为 1.46（95% CI，1.14-1.85），重度 TBI 患者为 1.18（95% CI，1.03-1.55）。当从 TARN 中排除伤后 6 小时内死亡的患者后，MEI 的作用与 IMPACT 和 CRASH 相当。
MEI 是 TBI 患者死亡率的一个重要预后因素。然而，其影响因人群而异，这解释了文献中的争议。在脑损伤更严重的患者中，其效果较弱，并取决于纳入研究的时间。
