Kelly Patrick D, Patel Pious D, Yengo-Kahn Aaron M, Wolfson Daniel I, Dawoud Fakhry, Ahluwalia Ranbir, Guillamondegui Oscar D, Bonfield Christopher M
1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville.
2Vanderbilt University School of Medicine, Nashville.
J Neurosurg. 2021 Mar 9;135(5):1550-1559. doi: 10.3171/2020.9.JNS202723. Print 2021 Nov 1.
Several scores estimate the prognosis for gunshot wounds to the head (GSWH) at the point of hospital admission. However, prognosis may change over the course of the hospital stay. This study measures the accuracy of the Baylor score among patients who have already survived the acute phase of hospitalization and generates conditional outcome curves for the duration of hospital stay for patients with GSWH.
Patients in whom GSWH with dural penetration occurred between January 2009 and June 2019 were identified from a trauma registry at a level I trauma center in the southeastern US. The Baylor score was calculated using component variables. Conditional overall survival and good functional outcome (Glasgow Outcome Scale score of 4 or 5) curves were generated. The accuracy of the Baylor score in predicting mortality and functional outcome among acute-phase survivors (survival > 48 hours) was assessed using receiver operating characteristic curves and the area under the curve (AUC).
A total of 297 patients were included (mean age 38.0 [SD 15.7] years, 73.4% White, 85.2% male), and 129 patients survived the initial 48 hours of admission. These acute-phase survivors had a decreased mortality rate of 32.6% (n = 42) compared to 68.4% (n = 203) for all patients, and an increased rate of good functional outcome (48.1%; n = 62) compared to the rate for all patients (23.2%; n = 69). Among acute-phase survivors, the Baylor score accurately predicted mortality (AUC = 0.807) and functional outcome (AUC = 0.837). However, the Baylor score generally overestimated true mortality rates and underestimated good functional outcome. Additionally, hospital day 18 represented an inflection point of decreasing probability of good functional outcome.
During admission for GSWH, surviving beyond the acute phase of 48 hours doubles the rates of survival and good functional outcome. The Baylor score maintains reasonable accuracy in predicting these outcomes for acute-phase survivors, but generally overestimates mortality and underestimates good functional outcome. Future prognostic models should incorporate conditional survival to improve the accuracy of prognostication after the acute phase.
有几种评分方法可在医院入院时评估头部枪伤（GSWH）的预后。然而，预后可能在住院期间发生变化。本研究评估了贝勒评分在已经度过住院急性期的患者中的准确性，并生成了GSWH患者住院期间的条件性结局曲线。
从美国东南部一家一级创伤中心的创伤登记处识别出2009年1月至2019年6月期间发生硬脑膜穿透的GSWH患者。使用组成变量计算贝勒评分。生成条件性总体生存率和良好功能结局（格拉斯哥结局量表评分为4或5）曲线。使用受试者工作特征曲线和曲线下面积（AUC）评估贝勒评分在预测急性期幸存者（存活>48小时）的死亡率和功能结局方面的准确性。
共纳入297例患者（平均年龄38.0[标准差15.7]岁，73.4%为白人，85.2%为男性），129例患者在入院最初48小时内存活。这些急性期幸存者的死亡率为32.6%（n = 42），低于所有患者的68.4%（n = 203），良好功能结局的发生率为48.1%（n = 62），高于所有患者的发生率（23.2%；n = 69）。在急性期幸存者中，贝勒评分准确预测了死亡率（AUC = 0.807）和功能结局（AUC = 0.837）。然而，贝勒评分通常高估了实际死亡率，低估了良好功能结局。此外，第18个住院日代表了良好功能结局概率下降的转折点。
在GSWH患者住院期间，存活超过48小时的急性期会使生存率和良好功能结局的发生率翻倍。贝勒评分在预测急性期幸存者的这些结局方面保持了合理的准确性，但通常高估了死亡率，低估了良好功能结局。未来的预后模型应纳入条件性生存情况，以提高急性期后预后的准确性。
