对颅内出血且 GCS 评分为 13 至 15 的患者常规重复颅脑 CT 扫描的前瞻性评估。
A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15.
机构信息
Department of Surgery, Division of Burns, Trauma, and Critical Care, The University of Texas-Southwestern Medical Center, Dallas, Texas 75390-9148, USA.
出版信息
J Trauma Acute Care Surg. 2012 Sep;73(3):685-8. doi: 10.1097/TA.0b013e318265ccd9.
BACKGROUND
Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores.
METHODS
This prospective cohort study followed all patients presenting to our urban Level I trauma center with intracranial hemorrhage and a GCS score of 13 to 15 from February 2010 to December 2010. Subjects were divided into two groups: those in whom repeat CT scans were performed routinely (ROUTINE) and those in whom they were performed selectively (SELECTIVE) based on changes in clinical examination. CT scanning decisions were made at the discretion of the neurosurgical service attending physician.
RESULTS
One hundred forty-five patients met the inclusion criteria (ROUTINE, n = 92; SELECTIVE, n = 53). Group demographics, including age, sex, and presenting GCS score were not significantly different. Of SELECTIVE patients, six (11%) required a repeat head computed tomography for a neurologic change, with one having a radiographic progression of hemorrhage (16%) versus 26 (28%) of 92 in the ROUTINE group showing a radiographic progression. No patient in either group required medical or neurosurgical intervention based on repeat scan. The number of CT scans performed differed between the two groups (three scans in ROUTINE vs. one scan in SELECTIVE, p < 0.001), as did the intensive care unit (2 days vs. 1 day, p < 0.001) and hospital (5 days vs. 2 days, p < 0.001) lengths of stay. Discharge GCS score was similar for both groups (15 vs. 15, p = 0.37). One death occurred in the SELECTIVE group, unrelated to intracranial findings. The negative predictive value of a repeat CT scan leading to neurosurgical intervention with no change in clinical examination was 100% for both groups.
CONCLUSION
A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores.
LEVEL OF EVIDENCE
Diagnostic study, level II.
背景
轻度创伤性脑损伤后的计划重复头部计算机断层扫描已被证明对预测干预需求的作用有限。我们假设，对于颅内出血且格拉斯哥昏迷量表（GCS）评分为 13 至 15 分且无神经症状进展的患者，重复计算机断层扫描不会影响神经外科干预的需求或出院时的 GCS 评分。
方法
本前瞻性队列研究纳入了 2010 年 2 月至 2010 年 12 月期间我院收治的所有颅内出血且 GCS 评分为 13 至 15 分的患者。根据临床检查的变化，将患者分为两组：常规进行重复 CT 扫描的患者（常规组）和选择性进行重复 CT 扫描的患者（选择组）。CT 扫描决策由神经外科主治医生决定。
结果
共有 145 名患者符合纳入标准（常规组，n = 92；选择组，n = 53）。两组患者的人口统计学特征，包括年龄、性别和入院时的 GCS 评分均无显著差异。在选择组中，有 6 名（11%）患者因神经变化需要重复头部计算机断层扫描，其中 1 名患者的出血有影像学进展（16%），而常规组的 92 名患者中有 26 名（28%）显示影像学进展。两组均未因重复扫描而需要进行药物或神经外科干预。两组的 CT 扫描次数不同（常规组 3 次，选择组 1 次，p < 0.001），两组的重症监护病房（ICU）住院时间（常规组 2 天，选择组 1 天，p < 0.001）和住院时间（常规组 5 天，选择组 2 天，p < 0.001）也不同。两组的出院 GCS 评分相似（常规组 15 分，选择组 15 分，p = 0.37）。选择组有 1 例死亡，与颅内发现无关。在两组中，重复 CT 扫描后无神经外科干预且临床检查无变化的阴性预测值均为 100%。
结论
对入院时 GCS 评分为 13 至 15 分的创伤性脑损伤患者进行选择性重复头部 CT 扫描可减少该检查的使用，并与缩短住院时间相关，而不影响出院时的 GCS 评分。
证据水平
诊断研究，Ⅱ级。
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