1Department of Intensive Care Medicine, Royal Perth Hospital.
2School of Population and Global Health, University of Western Australia.
J Neurosurg. 2019 Feb 8;132(2):545-551. doi: 10.3171/2018.10.JNS182293. Print 2020 Feb 1.
Hematological abnormalities after severe traumatic brain injury (TBI) are common, and are associated with a poor outcome. Whether these abnormalities offer additional prognostic significance over and beyond validated TBI prognostic models is uncertain.
This retrospective cohort study compared the ability of admission hematological abnormalities to that of the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials) prognostic model to predict 18-month neurological outcome of 388 patients who required a decompressive craniectomy after severe TBI, between 2004 and 2016, in Western Australia. Area under the receiver operating characteristic (AUROC) curve was used to assess predictors' ability to discriminate between patients with and without an unfavorable outcome of death, vegetative state, or severe disability.
Of the 388 patients included in the study, 151 (38.9%) had an unfavorable outcome at 18 months after decompressive craniectomy for severe TBI. Abnormalities in admission hemoglobin (AUROC 0.594, p = 0.002), plasma glucose (AUROC 0.592, p = 0.002), fibrinogen (AUROC 0.563, p = 0.036), international normalized ratio (INR; AUROC 0.645, p = 0.001), activated partial thromboplastin time (AUROC 0.564, p = 0.033), and disseminated intravascular coagulation score (AUROC 0.623, p = 0.001) were all associated with a higher risk of unfavorable outcome at 18 months after severe TBI. As a marker of inflammation, neutrophil to lymphocyte ratio was not significantly associated with the risk of unfavorable outcome (AUROC 0.500, p = 0.998). However, none of these parameters, in addition to the platelet count, were significantly associated with an unfavorable outcome after adjusting for the IMPACT predicted risk (odds ratio [OR] per 10% increment in risk 2.473, 95% confidence interval [CI] 2.061-2.967; p = 0.001). After excluding 8 patients (2.1%) who were treated with warfarin prior to the injury, there was a suggestion that INR was associated with some additional prognostic significance (OR 3.183, 95% CI 0.856-11.833; p = 0.084) after adjusting for the IMPACT predicted risk.
In isolation, INR was the best hematological prognostic parameter in severe TBI requiring decompressive craniectomy, especially when patients treated with warfarin were excluded. However, the prognostic significance of admission hematological abnormalities was mostly captured by the IMPACT prognostic model, such that they did not offer any additional prognostic information beyond the IMPACT predicted risk. These results suggest that new prognostic factors for TBI should be evaluated in conjunction with predicted risks of a comprehensive prognostic model that has been validated, such as the IMPACT prognostic model.
严重创伤性脑损伤（TBI）后出现血液学异常较为常见，且与不良预后相关。这些异常是否比经过验证的 TBI 预后模型提供了额外的预后意义尚不确定。
本回顾性队列研究比较了入院时血液学异常与 IMPACT（国际创伤预后分析临床试验）预后模型对 2004 年至 2016 年间在西澳大利亚接受去骨瓣减压术的 388 例严重 TBI 患者的 18 个月神经预后的预测能力。受试者工作特征（ROC）曲线下面积（AUROC）用于评估预测因子区分预后不良（死亡、植物状态或严重残疾）患者和无不良预后患者的能力。
在研究的 388 例患者中，151 例（38.9%）在严重 TBI 行去骨瓣减压术后 18 个月预后不良。入院时血红蛋白（AUROC 0.594，p=0.002）、血浆葡萄糖（AUROC 0.592，p=0.002）、纤维蛋白原（AUROC 0.563，p=0.036）、国际标准化比值（INR；AUROC 0.645，p=0.001）、活化部分凝血活酶时间（AUROC 0.564，p=0.033）和弥散性血管内凝血评分（AUROC 0.623，p=0.001）异常均与严重 TBI 后 18 个月不良预后风险增加相关。作为炎症标志物的中性粒细胞与淋巴细胞比值与不良预后风险无显著相关性（AUROC 0.500，p=0.998）。然而，在调整 IMPACT 预测风险后，除血小板计数外，这些参数均与不良预后无显著相关性（每增加 10%风险的比值比[OR]为 2.473，95%置信区间[CI]为 2.061-2.967；p=0.001）。排除 8 例（2.1%）受伤前接受华法林治疗的患者后，提示 INR 具有一定的附加预后意义（调整 IMPACT 预测风险后的 OR 为 3.183，95%CI 为 0.856-11.833；p=0.084）。
在需要去骨瓣减压术的严重 TBI 中，INR 是最好的血液学预后参数，尤其是排除接受华法林治疗的患者时。然而，入院时血液学异常的预后意义主要被 IMPACT 预后模型所捕获，因此，它们并没有提供任何超出 IMPACT 预测风险的额外预后信息。这些结果表明，新的 TBI 预后因素应与经过验证的综合预后模型（如 IMPACT 预后模型）的预测风险一起进行评估。
