Matsushima Kazuhide, Inaba Kenji, Siboni Stefano, Skiada Dimitra, Strumwasser Aaron M, Magee Gregory A, Sung Gene Y, Benjaminm Elizabeth R, Lam Lydia, Demetriades Demetrios
From the Divisions of Acute Care Surgery (K.M., K.I., S.S., D.S., A.M.S., G.A.M., E.R.B., L.L., D.D.), and Neurocritical Care and Stroke (G.Y.S.), University of Southern California, Los Angeles, California.
J Trauma Acute Care Surg. 2015 Nov;79(5):838-42. doi: 10.1097/TA.0000000000000719.
It remains unclear whether the timing of neurosurgical intervention impacts the outcome of patients with isolated severe traumatic brain injury (TBI). We hypothesized that a shorter time between emergency department (ED) admission to neurosurgical intervention would be associated with a significantly higher rate of patient survival.
Our institutional trauma registry was queried for patients (2003-2013) who required an emergent neurosurgical intervention (craniotomy, craniectomy) for TBI within 300 minutes after the ED admission. We included patients with altered mental status upon presentation in the ED (Glasgow Coma Scale [GCS] score < 9). Patients with associated severe injuries (Abbreviated Injury Scale [AIS] score ≥ 2) in other body regions were excluded. In-hospital mortality of patients who underwent surgery in less than 200 minutes (early group) was compared with those who underwent surgery in 200 minutes or longer (late group) using univariate and multivariate analyses.
A total of 161 patients were identified during the study time frame. Head computed tomographic scan demonstrated subdural hematoma in 85.8%, subarachnoid hemorrhage in 55.5%, and equal numbers of epidural hematoma and intraparenchymal hemorrhage in 22.6%. Median time between ED admission and neurosurgical intervention was 133 minutes. In univariate analysis, a significantly lower in-hospital mortality rate was identified in the early group (34.5% vs. 59.1%, p = 0.03). After adjusting for clinically important covariates in a logistic regression model, early neurosurgical intervention was significantly associated with a higher odds of patient survival (odds ratio, 7.41; 95% confidence interval, 1.66-32.98; p = 0.009).
Our data suggest that the survival rate of isolated severe TBI patients who required an emergent neurosurgical intervention could be time dependent. These patients might benefit from expedited process (computed tomographic scan, neurosurgical consultation, etc.) to shorten the time to surgical intervention.
Prognostic study, level IV.
目前尚不清楚神经外科手术干预的时机是否会影响单纯性严重创伤性脑损伤（TBI）患者的预后。我们假设急诊科（ED）入院至神经外科手术干预之间的时间越短，患者生存率越高。
查询我们机构的创伤登记系统，找出2003年至2013年间在ED入院后300分钟内需要紧急神经外科手术干预（开颅手术、颅骨切除术）治疗TBI的患者。我们纳入了在ED就诊时意识状态改变（格拉斯哥昏迷量表[GCS]评分<9）的患者。排除其他身体部位伴有严重损伤（简明损伤量表[AIS]评分≥2）的患者。采用单因素和多因素分析比较手术时间少于200分钟的患者（早期组）和手术时间在200分钟及以上的患者（晚期组）的院内死亡率。
在研究时间段内共确定了161例患者。头部计算机断层扫描显示，85.8%的患者有硬膜下血肿，55.5%的患者有蛛网膜下腔出血，22.6%的患者硬膜外血肿和脑实质内出血的数量相等。ED入院至神经外科手术干预的中位时间为133分钟。在单因素分析中，早期组的院内死亡率显著较低（34.5%对59.1%，p = 0.03）。在逻辑回归模型中对临床重要协变量进行校正后，早期神经外科手术干预与患者生存几率显著相关（优势比，7.41；95%置信区间，1.66 - 32.98；p = 0.009）。
我们的数据表明，需要紧急神经外科手术干预的单纯性严重TBI患者的生存率可能与时间有关。这些患者可能受益于加快流程（计算机断层扫描、神经外科会诊等）以缩短手术干预时间。
预后研究，IV级。
