From the Section of Surgical Sciences, Division of Trauma and Surgical Critical Care, Departments of Surgery and Neurosurgery (S.S.H., M.A.S., J.C.S., M.F.M., M.B.P.), Vanderbilt Brain Institute, Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee; College of Medicine (S.S.H.), University of Tennessee Health Science Center (UTHSC), Memphis, Tennessee; Department of Communication Sciences and Disorders (L.D.W.), Oxley College of Health Sciences, The University of Tulsa, Tulsa, Oklahoma; Department of Hearing and Speech Sciences (L.D.W., M.B.P.), Department of Biostatistics (L.W.), Vanderbilt University School of Medicine (D.A.L., J.C.S., A.B., S.P., M.A.D., M.B.P.), Nashville, Tennessee; Department of Emergency Medicine (D.A.L.), San Antonio Military Medical Center, Fort Sam Houston, Texas; Vanderbilt University (M.A.S.); Meharry Medical College, Nashville, Tennessee; (M.A.S.); Department of Radiology and Radiological Sciences (A.B., S.P., M.A.D.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Neurology (S.M.), University of Massachusetts Medical School, University of Massachusetts Medical Center, Worcester, Massachusetts; and Surgical Service, General Surgery Section, Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center (M.B.P.), Tennessee Valley Health Care System, Nashville, Tennessee.
J Trauma Acute Care Surg. 2018 Jul;85(1):155-159. doi: 10.1097/TA.0000000000001852.
Determine the prognostic impact of magnetic resonance imaging (MRI)-defined diffuse axonal injury (DAI) after traumatic brain injury (TBI) on functional outcomes, quality of life, and 3-year mortality.
This retrospective single center cohort included adult trauma patients (age > 17 years) admitted from 2006 to 2012 with TBI. Inclusion criteria were positive head computed tomography with brain MRI within 2 weeks of admission. Exclusion criteria included penetrating TBI or prior neurologic condition. Separate ordinal logistic models assessed DAI's prognostic value for the following scores: (1) hospital-discharge Functional Independence Measure, (2) long-term Glasgow Outcome Scale-Extended, and (3) long-term Quality of Life after Brain Injury-Overall Scale. Cox proportional hazards modeling assessed DAI's prognostic value for 3-year survival. Covariates included age, sex, race, insurance status, Injury Severity Score, admission Glasgow Coma Scale Score, Marshall Head computed tomography Class, clinical DAI on MRI (Y/N), research-level anatomic DAI Grades I-III (I, cortical; II, corpus callosum; III, brainstem), ventilator days, time to follow commands, and time to long-term follow-up (for logistic models).
Eligibility criteria was met by 311 patients, who had a median age of 40 years (interquartile range [IQR], 23-57 years), Injury Severity Score of 29 (IQR, 22-38), intensive care unit stay of 6 days (IQR, 2-11 days), and follow-up of 5 years (IQR, 3-6 years). Clinical DAI was present on 47% of MRIs. Among 300 readable MRIs, 56% of MRIs had anatomic DAI (25% Grade I, 18% Grade II, 13% Grade III). On regression, only clinical (not anatomic) DAI was predictive of a lower Functional Independence Measure score (odds ratio, 2.5; 95% confidence interval, 1.28-4.76], p = 0.007). Neither clinical nor anatomic DAI were related to survival, Glasgow Outcome Scale-Extended, or Quality of Life after Brain Injury-Overall Scale scores.
In this longitudinal cohort, clinical evidence of DAI on MRI may only be useful for predicting short-term in-hospital functional outcome. Given no association of DAI and long-term TBI outcomes, providers should be cautious in attributing DAI to future neurologic function, quality of life, and/or survival.
Epidemiological, level III; Therapeutic, level IV.
确定创伤性脑损伤（TBI）后磁共振成像（MRI）定义的弥漫性轴索损伤（DAI）对功能结局、生活质量和 3 年死亡率的预后影响。
本回顾性单中心队列纳入了 2006 年至 2012 年期间因 TBI 入院的成年创伤患者（年龄>17 岁）。纳入标准为头部 CT 阳性伴入院 2 周内脑 MRI。排除标准包括穿透性 TBI 或既往神经疾病。单独的有序逻辑模型评估 DAI 对以下评分的预后价值：（1）出院时功能独立性测量，（2）长期格拉斯哥结局扩展量表，和（3）脑损伤后长期生活质量综合量表。Cox 比例风险模型评估 DAI 对 3 年生存率的预后价值。协变量包括年龄、性别、种族、保险状况、损伤严重程度评分、入院格拉斯哥昏迷评分、马歇尔头 CT 分级、MRI 上的临床 DAI（Y/N）、研究级解剖学 DAI I-III 级（I，皮质；II，胼胝体；III，脑干）、呼吸机天数、听从命令的时间和长期随访时间（用于逻辑模型）。
311 名符合入选标准的患者，中位年龄 40 岁（四分位距 [IQR]，23-57 岁），损伤严重程度评分 29（IQR，22-38），重症监护病房住院 6 天（IQR，2-11 天），随访 5 年（IQR，3-6 年）。47%的 MRI 上有临床 DAI。在 300 份可读的 MRI 中，56%的 MRI 有解剖学 DAI（25%为 I 级，18%为 II 级，13%为 III 级）。回归分析显示，只有临床（而非解剖学）DAI 与较低的功能独立性测量评分相关（优势比，2.5；95%置信区间，1.28-4.76]，p=0.007）。临床和解剖学 DAI 均与生存、格拉斯哥结局扩展量表或脑损伤后生活质量综合量表评分无关。
在本纵向队列中，MRI 上的临床 DAI 证据可能仅有助于预测短期院内功能结局。鉴于 DAI 与长期 TBI 结局无关联，临床医生在将 DAI 归因于未来的神经功能、生活质量和/或生存时应谨慎。
流行病学，III 级；治疗学，IV 级。
