Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK.
BMJ Open. 2013 Dec 17;3(12):e003684. doi: 10.1136/bmjopen-2013-003684.
To identify factors associated with the decision to transfer and/or operate on patients with intracerebral haemorrhage (ICH) at a UK regional neurosurgical centre and test whether these decisions were associated with patient survival.
Retrospective cohort study.
14 acute and specialist hospitals served by the neurosurgical unit at Salford Royal NHS Foundation Trust, Salford, UK.
All patients referred acutely to neurosurgery from January 2008 to October 2010.
Primary outcome was survival and secondary outcomes were transfer to the neurosurgical centre and acute neurosurgery.
We obtained clinical data from 1364 consecutive spontaneous patients with ICH and 1175 cases were included in the final analysis. 140 (12%) patients were transferred and 75 (6%) had surgery. In a multifactorial analysis, the decision to transfer was more likely with younger age, women, brainstem and cerebellar location and larger haematomas. Risk of death in the following year was higher with advancing age, lower Glasgow Coma Scale, larger haematomas, brainstem ICH and intraventricular haemorrhage. The transferred patients had a lower risk of death relative to those remaining at the referring centre whether they had surgery (HR 0.46, 95% CI 0.32 to 0.67) or not (HR 0.41, 95% CI 0.22 to 0.73). Acute management decisions were included in the regression model for the 227 patients under either stroke medicine or neurosurgery at the neurosurgical centre and early do-not-resuscitate orders accounted for much of the observed difference, independently associated with an increased risk of death (HR 4.8, 95% CI 2.7 to 8.6).
The clear association between transfer to a specialist centre and survival, independent of established prognostic factors, suggests aggressive supportive care at a specialist centre may improve survival in ICH and warrants further investigation in prospective studies.
确定与英国地区神经外科中心对颅内出血（ICH）患者进行转院和/或手术的决策相关的因素，并检验这些决策是否与患者的生存情况相关。
回顾性队列研究。
英国索尔福德皇家 NHS 基金会信托的神经外科病房，由 14 家急性病医院和专科医院提供服务。
2008 年 1 月至 2010 年 10 月期间急性转至神经外科的所有ICH 患者。
主要结局是生存情况，次要结局是转至神经外科中心和接受急性神经外科治疗。
我们从 1364 例连续自发性ICH 患者中获取了临床数据，最终有 1175 例病例纳入了最终分析。140 例（12%）患者被转院，75 例（6%）接受了手术。多因素分析显示，更年轻的年龄、女性、脑桥和小脑位置以及更大的血肿更容易导致转院决策。在接下来的一年中，年龄增长、格拉斯哥昏迷量表评分降低、血肿增大、脑桥ICH 和脑室内出血与更高的死亡风险相关。相对于留在转诊中心的患者，无论是否接受手术，转院患者的死亡风险均较低（手术患者 HR 0.46，95%CI 0.32 至 0.67；未手术患者 HR 0.41，95%CI 0.22 至 0.73）。在神经外科中心的脑卒中医学或神经外科治疗下的 227 例患者中，将急性管理决策纳入回归模型，早期不复苏医嘱是观察到的差异的主要原因，独立地与死亡风险增加相关（HR 4.8，95%CI 2.7 至 8.6）。
与转至专业中心的明显相关性与生存情况相关，独立于既定的预后因素，提示在专业中心积极的支持性治疗可能改善ICH 的生存情况，值得进一步在前瞻性研究中进行探索。
